Question

Ellen Hernandez, a nurse on the medical-surgical unit, meets her newly assigned client, Sandy McDonald, a pretty, petite woman who was admitted for exploratory laparotomy. Mrs. McDonald appears anxious and worried. She tells her nurse that she is concerned about the surgery tomorrow and has been anxious for a week, ever since her doctor told her there is a possibility of finding a malignant tumor. The client says, “I haven’t been able to pay attention to anyone since then. I’m afraid there will be bad news.” Restlessly she adjusts the bedclothes. “Would you mind telling me your name again?” she asks Ms. Hernandez.

The nurse reviews the next day’s surgical procedure with Mrs. McDonald. With some prompting, the client is able to comprehend and follow the nurse’s directions. She suddenly begins tapping her fingers on the overbed table and tells the nurse “I have a headache.” “Will I still have to have surgery?”

The nurse checks Sandy’s vitals and finds that her blood pressure and pulse are elevated. When her husband arrives he appears as anxious as his wife. “I’m scared to death,” he says. “I’m just hoping the diagnosis is good.”

Assessment

Objective Data

Subjective Data

Nurse’s Personal Perspective

Diagnosis

Outcomes Identification

Planning

Implementation

Short-Term Goals

Intervention

Rationale

Evaluation

Evaluation

Answer 1

ASSESSMENT

Subjective data :- Mrs Mcdonald tells that "I am worried about my disease and surgery (exploratory laprotomy).

Objective data :-

Patient has,

• Appears anxious and worried
• Poor eye contact
• Restlesness present
• Headache present
• Elevated blood pressure and pulse

NURSES PERSONAL PERSPECTIVE

Diagnosis :-

​Anxiety related to upcoming surgery as evidence by her Restlesness and facial expressions

Outcome identification :-

• Client will demonstrate absence of physical manifestation of anxiety.
• Client will identify indicators of own anxiety.
• Client will verbalise feeling of anxiety appropriately
• Client will demonstrate the use new copping skills.

Planning :-

After 2 hours of nursing interventions, Patient will appear relaxed and the level of anxiety is reduced to manageable level.

Implementation :-

• Assessed the patient level of anxiety
• Monitored vital signs
• Instructed to do deep breathing exercises
• Provided a accurate information about the situation
• Established a therapeutic relationship, conveying empathy and unconditional positive reward, maintain a calm manner while interacting with patient.
• Established a working relationship with the patient through continuity care
• Used simple languages and brief statements

Short - Term goals :-

• Respond to relaxation techniques with decreased anxiety.
• Effectively decrease own anxiety level.
• Decrease avoidance behaviour.
• Manage the anxiety response effectively.

Intervention :-

• Assess the patient anxiety level.
• Monitor vital signs
• Acknowledge awareness of patient's anxiety.
• Instruct to do deep breathing exercises.
• Provides a accurate information about the situation
• Establish a therapeutic relationship, conveying empathy and unconditional positive reward, maintain a calm manner while interacting with patient.
• Establish a working relationship with the patient through continuity care
• Use simple languages and brief statements.

Rationale :-

• Difference level of anxiety will affect the coping mechanism of the client
• To identify physical responses associated with both medical and emotional conditions
• Acknowledgement of the patient's feeling validates the feeling and communicate acceptance of these feelings
• Deep breathing exercises helps to relax
• Accurate informations helps client to identify what is the reality based.

Evaluation :-

After 2 hours of nursing interventions, Patient was appear relaxed and the level of anxiety is reduced to manageable level.