Help with careplan???

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I am currently trying to do my care plan on the patient I had last week.. My nursing diagnosis is: Anxiety related to current hospitalization, NG placement, and husbands admission and pending surgical procedure manifested by sleeplessness, NG tube guarding and constant reference to husband's health status. My problem not is creating a patient goal which is measureable, patient centered, and has a time. How an you measure a personss anxiety? Just by what the verbally tell you?

Any suggestions!!!

Melanie:bow:

jewelsg627

146 Posts

I would say shows a reduction in s/s of anxiety (i.e - restlessness) AND verbally states a reduction in anxiety

Did that help?

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

well, first of all your diagnostic statement is not constructed correctly as i'm looking at it. i can see "situational crisis" as being the etiology, or cause of her anxiety, but much of the other stuff you have listed are actually symptoms, or defining characteristics of the anxiety, and do not belong in the place of the related factor.

everything in a care plan is based upon the symptoms that your patient has. the nursing diagnosis, goals and nursing interventions are all based upon the patient's symptoms, in this case, the symptoms of the anxiety. if you have a nursing diagnosis reference, you will see a listing of the symptoms, or defining characteristics, for the nursing diagnosis of anxiety. they are:

  • behavioral
    • diminished productivity
    • expressed concerns due to change in life events
    • extraneous movement
    • fidgeting
    • glancing about
    • insomnia
    • poor eye contact
    • restlessness
    • scanning
    • vigilance

    [*]affective

    • apprehensive
    • anguish
    • distressed
    • fearful
    • feelings of inadequacy
    • focus on self
    • increased wariness
    • irritability
    • jittery
    • overexcited
    • painful increased helplessness
    • persistent increased helplessness
    • rattled
    • regretful
    • scared
    • uncertainty
    • worried

    [*]physiological

    • facial tension
    • hand tremors
    • increased perspiration
    • increased tension
    • shakiness
    • trembling
    • voice quivering

    [*]sympathetic

    • anorexia
    • cardiovascular excitation
    • diarrhea
    • dry mouth
    • facial flushing
    • heart pounding
    • increased blood pressure
    • increased pulse
    • increased reflexes
    • increased respiration
    • pupil dilation
    • respiratory difficulties
    • superficial vasoconstriction
    • twitching
    • weakness

    [*]parasympathetic

    • abdominal pain
    • decreased blood pressure
    • decreased pulse
    • diarrhea
    • faintness
    • fatigue
    • nausea
    • sleep disturbance
    • tingling in extremities
    • urinary frequency
    • urinary hesitancy
    • urinary urgency

    [*]cognitive

    • awareness of physiologic symptoms
    • blocking of thought
    • confusion
    • decreased perceptual field
    • difficulty concentrating
    • diminished ability to learn
    • diminished ability to problem solve
    • fear of unspecified consequences
    • forgetfulness
    • impaired attention
    • preoccupation
    • rumination
    • tendency to blame others

    [*]from page 9 - 10 of nanda-i nursing diagnoses: definitions & classification 2007-2008

your patient has a number of the above symptoms. a goal is your predicted result of your nursing actions (nursing interventions), those things that a nurse prescribes, or orders, for a patient on the care plan. an expected goal is measurable, patient centered, and specific. all nursing interventions are aimed at the patient's specific symptoms, or defining characteristics (nanda language), that they are displaying.

so, in order to write any goals for this patient, you must have a clear vision of what their symptoms of the anxiety are, what nursing interventions you plan to take and what you expect to accomplish by performing those interventions. remember that symptoms can be either subjective or objective. if you have subjective statements as symptoms then goal statements could also be subjective statements that you would expect the patient to make back to you after successful nursing interventions.

there is specific information on how to write goal statements on this post: https://allnurses.com/forums/2509305-post157.html

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