CAPITOL UNIVERSITY COLLEGE OF NURSING Name of Student: _________________________________________________ Name of Patient: _________________________________________________ NURSING CARE PLAN ASSESSMENT DATA

(Subjective & Objective Cues) Subjective: "di na jud ko makatrabaho ani sa bukid" as verbalized by the patient Anxiety related to threat to/ or Within 8 hours of change in health status patient will appear relaxed and the level of anxiety will reduced to a manageable level Objective: -RR- 20 -restlessness -difficulty in sleeping -fatigue 1. Monitor vital signs(e.g., rapid or R: To identify physical responses
associated with both medical and emotional conditions

Date of Assignment: _____________ Ward: ____________________ Bed No. __

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

After 8 hours of nursing interventions the patient appeared relaxed and the level of anxiety will reduced to a manageable level

nursing interventions the irregular pulse, rapid breathing)

2.

Use

presence,

touch,

verbalization or demeanor to remind client and to encourage expressions or clarification of needs, concerns, unknowns and questions R: Being supportive
and approachable encourages communication

3. Accept client's defenses, do not confront, argue and debate R: If defenses are not threatened, the client
may feel safe enough to look at the behavior

4. Allow and reinforce clients personal reaction towards the threatens to well being R: or otherwise expressing feeling
reduces anxiety

5. Explain everything necessary regarding the disease R: To educate the

patient regarding the disease to reduce anxiety

CAPITOL UNIVERSITY COLLEGE OF NURSING

Name of Student: _________________________________________________ ____________________________________________ Name of Patient: _________________________________________________ DRUG STUDY

Date of Assignment: Ward: ____________________ Bed No. _____________________

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/ PRECAUTIONS