UNIVERSITY OF THE PHILIPPINES MANILA

SCHOOL OF HEALTH SCIENCES PALO, LEYTE

IDENTIFICATION
OF
VULNERABLE INDIVIDUAL
(ASSESSMENT)

 Comprehensive Health History

 Gordon’s 11 Functional Health Pattern
 Review of System

Prepared by:
NIKKY ROSSEL B. FLORES
BSN-37th Batch

Submitted to:
OSCAR DE PAZ JR. ,RN,MAN
PROFESSOR UPM-SHS
 COMPREHENSIVE NURSING HEALTH HISTORY

Date: June 7, 2019

I. BIOGRAPHICAL DATA:
a. Name: AYLA JAVIER
b. Address: Barangay, Naga-Naga, Palo, Leyte
c. Age: 20 years old
d. Sex: Female
e. Civil Status: Single
f. Date of Birth: March 10, 1999
g. Religion: Roman, Catholic
h. Occupation: Student
i. Mother: Merlyn P. Javier
j. Father: Rolando A. Javier
k. Ordinal Position: First
l. Type of Service: N/A
m. Source of Information: Primary
n. Attending Physician: N/A

II. REASON FOR SEEKING CARE (CHIEF COMPLAINT):

Identified vulnerable and risk group for mental health problem.

III. HISTORY OF PRESENT ILLNESS:

This is a case of Ayla Javier, 20 years old, single, a resident of Barangay Naga-Naga, Palo, Leyte. She is a
college student taking Bachelor of Science in Education major in Filipino my identified vulnerable group for
mental health. She is alert and active during interview and conscious about her present condition. She
experience worries and pressure about her studies but there are no preoccupations, changes in mood,
suspicions, delusions or hallucinatory experiences, recent change in sleep, appetite, concentration, memory,
or behavior, including suicidal or aggressive behavior. There is no severity on patient’s condition. There are
no associated features of specific psychiatric syndromes like (pertinent positive or negative factors) present
or absent during the present illness. The factors that patient believe that precipitating, aggravating or modify
the illness are related to her studies. Patient did not receive any treatment or other clinicians.

IV. PAST HEALTH HISTORY:

a. Childhood and Infectious Diseases:
In past history about childhood and infectious disease. Patient verbalizes that she had chicken pox at
the age of 6 years old and she experience common infectious diseases such as cough, cold and flu.

b. Immunizations:
She was fully immunized but cannot recall what specific vaccine.

c. Allergies:
She has no known allergies.

d. Medications Taken:
Medication taken are vitamins (Ferrous sulfate, vitamin C) Stress tabs once a day.

e. Major Surgeries and Previous Hospitalizations:

There are no major surgeries and previous hospitalization.

f. Injuries:
She has no known injuries.
V. FAMILY HISTORY:

VI. PSYCHOSOCIAL HISTORY AND LIFESTYLE:

a. Alcohol Use: Patient drinks alcohol occasionally (2-4) glasses only ( moderate)
b. Drug Use: No history of drug use
c. Tobacco Use: No history of tobacco use
d. Domestic and Intimate Partner Violence: She has no history domestic and Intimate Partner Violence
e. Sexual Practice: She has a boyfriend and claimed to have a sexual practice but limited information shared.
f. Travel History: No history of travel outside the country only domestic.
g. Work Environment: Not yet working. She is still a student.
h. Home Environment: She is living with her family and as eldest she assumes all the task when she’s home.
i. Hobbies and Leisure Activities: She hang out with her friends sometimes but spend most of her time watching
movies.
j. Stress: Stress management is to go out with her friends and divert her attention on watching movies
k. Education: College level (taking Bachelor of Science in Secondary Education) 2nd year .
l. Economic Status: Dependent on her Family since she is still a student
m. Ethnic Background: No ethnic background
 GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

1. Health Perception – Health Management Pattern

She has a good health status in general. According to her, she defines health as free from any pain or illness.
She experience common colds and fever one to two times a year. She also stated that she is very conscious about her
health, whenever she’s sick her first priority was to get herself checked by a medical practitioner or a doctor. She also
takes vitamins such as (Ferrous Sulfate and Ascorbic Acid). Sometimes, if mild signs and symptoms such as flu she do
it by self-medication. She also comply any medication prescribed, use of health-promotion activities such as regular
exercise and annual check-ups.

2. Nutritional – Metabolic Management Pattern

She eats 3 to 4 times a day, usually eats breakfast with rice, egg and noodles. She likes rice, fried fish and
vegetables for lunch and for dinner. She drinks 5-6 glasses of water a day at about 1200-1400cc.She fond of
eating salty foods and foods high in cholesterol. The condition of skin, teeth, hair, nails, mucous membranes
are all good the Height of Patient in Normal to her Weight. Height=153cm , Weight= 55kilograms.
3. Elimination Pattern

She voided about 5 to 6 times a day with an amount of approximately 500-800ml/day. She passes out stool
regularly once a day. Appearance of Urine is amber yellow which is normal, stool appears to be soft and
yellow.
4. Activity - Exercise Pattern

She exercise regularly and considers doing household chores as a form of exercise since she does all the
household chores such as (laundry, cooking and cleaning all the house). She cleans the house and laundry
every other day. She also actively participates on school P.E exercises but this is done only once a week. Her
hobbies is hanging out with her friends and Volleyball.
5. Sleep – Rest Pattern

She sleeps for about 6-8 hours a day. But for weekends when there is no class she sleeps for about 8-9 hours.
Sometimes she does not feel rested well after sleeping. According to her, she experienced insomnia. This
happened only, when the time of her sleeping habit is exceeded. She usually sleeps at around 10PM and
wakes up at 5AM.
6. Cognitive – Perceptual Pattern

She did not have any sensory deficits. She is now on her 2nd year college level taking Bachelor of Science in
Education major in Filipino. She did not use a hearing aid or eyeglasses. Sensitive to superficial pain and is
able to read and write. No difficulty on communicating or aphasia.
7. Self-Perception – Self-Concept Pattern

She most of the time feel good about herself, She has also a good self-esteem.
8. Roles – Relationships Pattern

Waray-waray as a primary dialect. She knows how to speak in English and Tagalog as well as Bisaya. She lives
with her 3 siblings, her Mother and Father. She is the eldest among 4 children.
9. Sexuality – Reproductive Pattern

She experience menarche at the age of 12. She has a boyfriend at the age of 20 and is aware about sexuality-
reproductive health since she has a subject about this on her first year in college.
10. Coping – Stress Tolerance Pattern

She experience stressful event and pressure on her studies since she’s a college student. When there was a
stressful event, she took stress tabs. Diverting her attention to watching television or going out with her
friends or classmates.
11. Values – Beliefs Pattern

She’s a Roman Catholic and she went to church regularly. She is a member of youth for Christ. She perceives
to finish her studies, got a job and make her parents proud as an important in life. There is none value-belief
conflicts related to health or any special religious practices.
 REVIEW OF SYSTEMS

1. Constitutional:
No problems on health, full of energy, no unexplained weight gain or weight loss, in good appetite,
no fever, night sweats or any pain.

2. Head, Eyes, Ears, Nose, Throat (HEENT):

There is no problem on difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in
ears, mouth sores, loose teeth, ear pain, nose bleeds, sore throat, facial pain or numbness.

3. Respiratory
(Lungs & Breathing)
No problem on shortness of breath, night sweats, prolonged cough, wheezing, sputum production,
any lung disease or problem, pleurisy, coughing of blood.

4. Cardiac
(Heart & Blood Vessels)
No identified irregular heartbeat, racing heart, chest pains, swelling of feet and legs, any pain at legs
while walking.

5. Gastrointestinal
(Stomach & Intestines)
No problem on heartburn, constipation, any intolerance to certain foods, diarrhea, abdominal pain,
difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits,
incontinence.

6. GenitoUrinary
(Kidney and Bladder)
There is no problem on painful urination, frequent urination, no urgency, problems on Urinary tract,
bladder problems or impotence.

7. Neuromuscular:
(Muscles, Bones, Joints)
No problems on joint pains, aching muscles, shoulder pain, swelling of joints, any joint deformities
only back pain maybe because of her position when she washed their clothes.
8. Neurologic
(Brain & Nerves)
No problems on frequent headaches, double vision, weakness, change in sensation, problems in
walking and balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of
visual loss.
9. Psychiatric
(Mood & Thinking)
With problems on Insomnia, but without any irritability, She has history of depression when she was
18 years because of a very sensitive issue. She has mild anxiety with no recurrent bad thoughts,
mood swings most especially during menstrual period, No hallucination and compulsions.
10. Hematological:
(Blood/Lymph)
No problems on easy bleeding, easy bruising, anemia, abnormal blood test, leukemia, unexplained
swollen areas.

11. Endocrinologic
(Glands)
No problems on intolerance to heat and cold, menstrual irregularities, frequent
hunger/urination/thirst.

12. Integrity
(Skin, Hair & Breast)
There is no persistent rash, aching, new skin lesion, change in existing skin lesions, hair loss or
increase, breast changes.

13. Allergic/Immunologic
No problems on seasonal allergies, hay fever symptoms, itching, frequent infection, exposure to HIV.
 LABORATORY SHEET

Laboratory Test: __________________________________ Date: _________________________

Component Normal Values Results Implication

Radiographic Test (i.e. x-rays, ultrasounds, angiography, etc.):

Results/Impression:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
 Process Recording

Personal Data
Name: Ayla Javier
Sex: Female
Age: 20 years’ old
Address: Brgy. Naga-Naga, Palo, Leyte
Birthday: March 10,1999
Religion: Roman Catholic
Occupation: Student
Living arrangement: 2nd yeal College

Description of Client
The client is single, a resident of Barangay Naga-Naga, Palo, Leyte. She is a college student
taking Bachelor of Science in Education major in Filipino my identified vulnerable group for mental
health. She is alert and active during interview and conscious about her present condition. She
experiences worries and pressure about her studies but there are no preoccupations, changes in mood,
suspicions, delusions or hallucinatory experiences, recent change in sleep, appetite, concentration,
memory, or behavior, including suicidal or aggressive behavior. There is no severity on patient’s
condition. There are no associated features of specific psychiatric syndromes like (pertinent positive
or negative factors) present or absent during the present illness. The factors that patient believe that
precipitating, aggravating or modify the illness are related to her studies. Patient did not receive any
treatment or other clinicians.

Description of the Environment

 The interview was done in her house. The environment was quiet and comfortable and relaxing. It was
clean and everything was well arranged. It was also safe. Overall the environment was conducive for a
productive conversation.

Objective of the Interaction

 Establish rapport
 Provide the client sufficient information about the interview
 Gather information about the client
 Assess and understand client’s thoughts, feelings and problems

Student Nurse Client’ Analysis

“Good afternoon Ayla, mag iinterview “anong subject po ate?
lang sana ko para sa isang subject
naming ngayon.”

“yung subject kasi namin ngayon “” Giving information about the

yung about sa mental health” interview to gain rapport and trust.

“ay hindi kuya, hindi ibig sabihin may

sakit ka nito, para din to sa mental “aw sige”
health promotion, naghahanap kami ng
mga vulnerable persons like mga
teenage mothers, senior citizens,mga
batang priso mga single tas nag isa na
medyo may edad na”
“ayaw na gad igbutang an akon
“sige kuya okay lang ba na ilagay ko ngaran okay man la diba kay
yung name mo dito?” makarawud?”

“okay kuya, walang problema kasi

para din naman sa privacy mo”
“ilan na edad mo ngayon kuya?”
“smiles and nods” “oo nga kuya”
“client laughs”
“Bata pa ako tapos na kuya kana” Gathering information
“client laughs”
“17 palang ako quez bata pa”
“client laughs again” Accepting by nodding to indicate
of following and hearing the train
of thought
“kelan yung birthday mo kuya?” “March 19, 2002”

“Oo gad” Gathering information

“catholic ka kuya?”
“Mayda ko uyab pero an adi na ak
“single ka ba kuya?” prisuhan nagbulag kami, pero yana
mayda ko bag o na uyab ha
facebook”
Client’s laugh

Student Nurse Client Analysis

“Taga saan naman jowa mo at ilang “Dulag, mag 18 palang”
taon? “client laughs”

“ano pangalan ng tatay at nanay mo “Carolina Nanos” Gathering information

kuya”? “an akon tatay Jerardo Nanos”

“okay kuya, pang ilan ka sa sa inyong “pito kami at pang anim akong anak nila,” Gathering information
magkapatid?

“Kumusta naman kayong “Ang iba adto manila nagtatrabaho at sila Exploring. To have an idea
magkakapatid?at family mo? nanay at tatay permi busy sa trabaho” and help analyze his
present situation.
“Anung trabaho ng magulang mo?” “Parag-uma”

“may nararamdaman ka ba ngayon, “Mayda ako sipon 3days na, ngan

kahit anong masakit?” nakukurian pagkaturog tungod kay mapaso
ngadi sulod ngan maaringasa”

“nagkaron kaba ng “waray” Gathering information

chickenpox/bulutong dati ?”

“eh yung mumps kuya? Yung bikag?” “nagkamayda gihap ak hito an elementary Gathering information
ako,”

“ahh okay (nods and maintains eye

contact)”
Active listening. Shows
“natandaan mo pa ba ung “oo kumpleto ako” interest and acceptance to
immunization mo? Kumpleto ba yung client
sayo?”

“allergies? “Waray man ako allergies sa pagkaun o bis Gathering information

anu”

“Neozep ng 500 mg para sa sipon ko” Gathering information

“ano man iniinom mong mga gamut
ngayun?”

“Nahospital kana ba?” “Waray simbako” Gathering information

Client’s laugh

“eh injuries? Aksidente sa sasakyan,

nabalian ka or mga ganun na “waray pero nagcrash na ako hin motor pero
injuries?” waray man ako piang,gasgas la”

“Kumusta ang yung pag aaral dati na “Maupay man,asya it akon namingawan tak Exploring. To have an idea
nasa labas kapa?” mga sangkay nga lurong” and help analyze his
Client’s laugh present situation.

“Bakit lurong?”

Student Nurse
“yung mga kapatid mo kuya? Buhay
pa lahat yung sa tatay mo?”
“Kuya sa pag inom, umiinom kaba?”
“kelan ka nagstop ng sigarilyo?
“drugs kuya, nagtry ka ba dati?”
“nods and maintains eye contact”
“nagtravel kaba nitong past year?
Kahit labas lng ng jail, o leyte, o kahit
sa ibang bansa?”
“ano man usually ginagawa mo, o
pampalipas oras?”
“anong nagpapastress sayo ngayon ?”
“anong year kana?
“para sayo kuya healthy kaba
ngayon?”
“para sayo ano bang healthy na tao?”
“smiles”
“ano man mga ginagawa mo para
maging healthy ka?”
“ano man usually mga kinakain mo
ngayon ?”
“yung tubig ? Malakas kaba uminom
ng tubig? Nakakaabot ka ng 8 na
baso?”
“kamusta naman yung pag ihi mo?
Okay naman? wlang problema?”
“ano man yung color ng ihi mo ?
Student Nurse
“yung pag tae mo kamusta naman?
May masakit ba? O nahihirapan?”
“Kay magkaupod ha tanan na
kalurungan,pag cutting ha
klase,panigarilyo,pag inum except la ha
pagdrugs.”
Client’s laugh
Client Analysis
“oo, buhay pa lahat, ou pero lahat sila adto Gathering information
na sa manila kami nala 3 ngada ha balay na
magburugto.an iba may asawa na”
“ou nainum ako tikang an naghighschool
ako, pati an sigarilyo”
“5 years na ada” Exploring. To have an idea
and help analyze his
“client smiles” “waray gad” present situation.
Gathering information
“Nakagawas la kami kun sugo nan jail
guard”
“nanonood ng TV, danay liwat bantay
tindahan kay duty man anmon ito ngadi”
“it akon kabutangan yana na bata pa ako Neutral response. Showing
napriso na ako,ngan it pagkita han mga tao interest and acceptance
ha akon” “client laughs” and being nonjudgmental.
Grade 9 Gathering information
“Di ko alam, bagat okay man la ako pero Gathering information
mayda ko sipon”
“syempre malakas yung katawan, waray gin
aabat,kumauon hin masustansya na pagkaun” Gathering information
“laughs”
“waray na ako nag inom ngan sigarilyo, Gathering information
syempre makaon hin healthy nga mga
pagkaon, jogging, nasaka hin bukid”
“kun anu it rasyon ngadi sulod asya la it Gathering information
akon nakakaun”
“oo nasobra pa ngani sa 8 nga baso okay Exploring. To have an idea
kelangan nasiring hi doc” and help analyze his
present situation.
“okay man, sige man tak ihi ihi kay damo
man tak gin iinom na tubig. Nkakadamo ak
pag ihi siguro mga 5 ka beses sa adlaw tapos
mga tulo kun gab e, mga alas dose, ala una,
ngan alas dos depende. Clear man tak ihi,
pero kung diri gud ak makainom hin damo
na tubig, madarag, pero an sakto la nga
darag”
Client Analysis
“nakakauro ko yana duha or tulo kada adlaw,
waray man ko nafeel nga masakit”
“yung pagtulog mo kamusta naman
?nahihirapan kaba matulog?”
“yung pagtingin mo naman kumusta?
Malabo ba o okay naman?”
“okay, yung sa hearing mo ? may
problem ba?”
“kumusta naman te yung pagtingin
mo sa self mo? Confident kaba sa self
mo?”
“aw oo” “smiles”
“May time ba na nafeel mo na
nawalan ka ng pag asa?”
“ano man ginagawa mo para
mabawasan yung lungkot mo na mag
isa?”
“minsan ba pumasok yung suicide sa
isip mo?”
“kelan te?”
“ano man yung ginawa mo para
mawala yun or maging okay ka?”
“May mga nagbago ba sayo,simula
nung nandyan ka?”
Student Nurse
“if ever dumating ka ulit sa point na
ganun ano yung pwede mong gawin
para maging okay ka o mawala yung
pag isip ng ganun?”
“nitong past year nagkaroon kaba ng
malaking problema?
“Diri gud ako nangangaturog hin tuhay,Kay
tungod mapaso ngan maaringasa ngan
minsan kun duty pagbantay asya piraw ak
yana”
“okay pa man.”
Exploring. To have an idea
and help analyze his
present situation.
“waray man gehap”
“ oo minsan, pero yana na akon sitwasyon
nawawarayan gad ako hin pag – asa saypa na Exploring. To have an idea
it pagkita it kadam an ha akon” and help analyze his
present situation.
“Danay kay namimingaw man tak pamilya
na panagsa ko la nakikita hira nanay ngan
tatay”
“videocall,pero tinagu-tago la liwat kay
bawal ngadi sakob” (laughs)
“kinausap din ako nung mga kasama ko
ngadi sakob”
“Ou an oras na nasugad ak hini pero kay ada
man hira nanay ngan tatay na nayakan kaya Exploring. To have an idea
ko ini ngan ada la hira ha akon” and help analyze his
present situation.
“Ginoo nala it bahala ha akon ngan hiya it
labi na maaram” Accepting to show interest
and listening.
“Ou, usa na an pakikisama ngan pagrespeto
ma bata man o nakakamagurang haak ngan Self-Disclosure and sharing
dako an ak paghinayang ngan pagbasol nga personal information to
nasulod ak hinin na sitwasyon kay nakarag convey understanding
an ak panahon”
Exploring. To have an idea
about her problem and help
her analyze and solve the
problem.
Client Analysis
“Amu la gihapon siguro, ada man la pirme Formulating a plan of
hira nanay ngan tatay ngan ada akon mga action to increase
patod na pwede ko kaistoryahon” likelihood that the client
will cope more effectively
next time in similar
situation
“asya man la ini aa akon dako na problema” Exploring. To have an idea
and help analyze his
present situation.
“ano man ginagawa mo para mawala
ung stress mo about jan sa problema
?”
“aw kaya mo yan lahat kuya, andyan
man lagi parents mo yung ibang
barkada mo din, andito din kami,
kung kelangan mo ng may makausap
or makasama”
“Sige , yun lang muna lahat. Salamat
sa time”
“nawawara man la ito na mga problema
parehas kung nagppray ako o kun nabusy,
pero nabalik liwat kun nag uusahan la ako”
“sige kuya quez salamat”
(smiles)
“salamat gihap kuya”
Exploring. To have an idea
and help analyze his
present situation.
Offering Hope. To keep her
in a more positive state of
mind
Offering self. Offeing to
time and attention to show
we value the patient
Recognition. Noting the
efforts the client has made.
 DRUG STUDY
Name General Action Specific Action Indication Side/Adverse Effects Nursing Consideration
Generic Name:

Brand/Trade Name:

Route:

Dosage:

Frequency:

Cues Nursing Diagnosis Rationale to Nursing
Diagnosis
Subjective Cues: Situational Low Self-esteem is defined After my nursing
Self-Esteem as the way an individual intervention the client:
“Nahihiya ako related to think about himself or
minsan kasi hindi ko bullying. herself, and how good
alam kung ako baa he or she feels. Positive
ng pinag-uusapan self-esteem develops
nila” as verbalized when a person feels
by patient. good and capable of
responding to
challenges and stressors.
Nevertheless, when a
person exhibits mild to a
remarkable shift in the
Objective Cues: view of himself or
-negative views on
herself such as
others
negativity about self,
-Lacks self-
low self-esteem
confidence
develops. Low self-
-lack of social
esteem can reduce the
interaction
quality of a person’s life
in many different ways,
including negative
feelings, fear,
relationship problems,
or low resilience. This
change in self-esteem is
a temporary phase in
response to feeling
helpless to control the
current situation.
( Nursing Diagnosis Handbook E-
Book: An Evidence-Based Guide to
Planning Care. Mosby.)
NURSING CARE PLAN
Goals and Objectives Nursing Interventions
-Act as a role model for the
patient or significant others
in healthy expression of
 Reports feelings or concerns.
progress in Assume responsibility for
current own thoughts and actions by
situation. using “I think” language in
 Verbalizes conversations.
positive self- Present an environment
acceptance. favorable to the expression
of feelings:
- Spend time with the
patient; set aside enough
time so that the encounter is
calm and deliberate.
-Provide privacy.
- Apply active listening and
open-ended questions.
Rationale to Nursing Evaluation
Interventions
-Patients may want an example
of positive measures to display
feelings. Self-awareness
enables the nurse to show
authentic behavior.
- Having enough time for the
patient conveys the nurse’s
interest in and acceptance of the
patient’s feelings. A trusting
relationship is an important
factor in building self-esteem.
- Private discussions need to
take place in a setting where the
patient is free to express
feelings without being
overheard.
- These communication
methods permit the patient to
verbalize interests, concerns,
worries, and thoughts without
interruption. This technique will
convey a sense of respect for
the patient’s abilities and
strengths in addition to
recognizing problems and
concerns.
- Consider the “normal”
impact of change on self-
esteem. Reassure the patient
that such modifications often
occur in a variety of
emotional or behavioral
responses.
- Support the patient in his or
her attempts to secure
autonomy, reality, positive
self-esteem, sense of
capability, and problem-
solving.
- Give anticipatory direction
to reduce anxiety and fear if
interference in self-esteem is
an expected part of the
process of adjustment to
changes in health status.
- Educate the patient to join
in activities anticipated to
result in healthy self-esteem.
- Present referral information
about community resources,
self-help groups, and
professional counseling.
- Educate the patient about
the harmful effects of
negative self-talk.
- Disturbances in self-esteem
are natural responses to
important changes.
Reconstitution of the patient’s
self-esteem occurs as part of the
patient’s adjustment to change.
- The patient needs continuous
positive feedback and support
to manage behaviors to promote
self-esteem. The patient will
benefit from feedback that
provides a realistic appraisal of
his or her development and
strengthens the effective change
made by the patient.
- The patient requires a view
that places the change in self-
esteem within the context of the
normal recuperative process.
- The patient needs to explore
options to improve self-esteem
by substituting negative
behaviors with positive actions.
- Professional and community
sources of support provide the
patient with more resources to
sustain the work of rebuilding
positive self-esteem.
- Recognition of unfavorable
thoughts can lift the patient to
develop new techniques for
coping. The patient must
replace negative beliefs and
ideas with positive thoughts
about self.
 NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective Cues: Sleep pattern Predisposing Factors: Patient obtains Independent
disturbance Environmental optimal amounts of -Maintain environment -To promote restful sleep.
“Hindi ako related to anxiety Disturbances and sleep as evidenced by conducive to sleep.
makatulog ng Stressors rested appearance,
maayos sa ↓ verbalization of -Assist patient in observing -To promote relaxation.
gabi” as Neurological feeling rested, and previous bedtime ritual.
verbalized by disturbances improvement in sleep
patient. ↓ pattern. -Provide nursing aids (back -To promote rest and
Impaired Reticular rub, bedtime care, pain relief, relaxation.
Formation Function comfortable position,
↓ relaxation techniques).
Manifestation of
difficulty of sleeping -Organize nursing care. -To promote minimal
Objective Cues: ↓ interruption in sleep/rest.
Sleeping Pattern
-early morning Disturbances -Increase day time physical -To reduce stress and promote
awakening activities as indicated. sleep
-difficulty in
falling or Collaborative
remaining asleep (Nursing Diagnosis Handbook E-
Book: An Evidence-Based Guide
-restlessness to Planning Care. Mosby.) -Administer hypnotics as - Use of hypnotics
-complaints of not ordered and evaluate medications should be
feeling rested effectiveness. thoughtful and avoided if less
aggressive means are
effective because of their
potential for cumulative
effects and generally limited
period of benefit.

Cues Nursing Rationale to Nursing
Diagnosis Diagnosis
Subjective Cues: Anxiety Anxiety is defined as
related to Vague uneasy feeling
situational of discomfort or
status. dread accompanied
by an autonomic
response (the source
often nonspecific or
unknown to the
individual); a feeling
of apprehension
caused by
anticipation of
Objective Cues: danger. It is an
alerting signal that
warns of impending
danger and enables
the individual to take
measures to deal with
the threat.
(Nursing Diagnosis Handbook
E-Book: An Evidence-Based
Guide to Planning Care.
Mosby.)
NURSING CARE PLAN
Goals and Objectives
-Patient describes own
anxiety and coping patterns.
-Patient demonstrates
improved concentration and
accuracy of thoughts.
-Patient demonstrates ability
to reassure self.
-Patient maintains a desired
level of role function and
problem-solving.
-Patient monitors signs and
intensity of anxiety.
-Patient identifies strategies
to reduce anxiety.
-Patient identifies and
verbalizes anxiety
precipitants, conflicts, and
threats.
-Patient demonstrates return
of basic problem-solving
skills.
-Patient demonstrates
increased external focus.
-Patient has vital signs that
reflect baseline or decreased
sympathetic stimulation.
-Patient has posture, facial
expressions, gestures, and
activity levels that reflect
decreased distress.
Nursing Interventions
-Recognize awareness of the
patient’s anxiety.
- Use presence, touch (with
permission), verbalization,
and demeanor to remind
patients that they are not
alone and to encourage
expression or clarification of
needs, concerns, unknowns,
and questions.
- Familiarize patient with the
environment and new
experiences or people as
needed.
- Interact with patient in a
peaceful manner.
Rationale to Nursing Evaluation
Interventions
- Since a cause of anxiety
cannot always be identified, the
patient may feel as though the
feelings being experienced are
counterfeit. Acknowledgment
of the patient’s feelings
validates the feelings and
communicates acceptance of
those feelings.
- Being supportive and
approachable promotes
communication.
- Awareness of the environment
promotes comfort and may
decrease anxiety experienced by
the patient. Anxiety may
intensify to a panic level if
patient feels threatened and
unable to control environmental
stimuli.
- The nurse or health care
provider can transmit his or her
own anxiety to the
hypersensitive patient. The
patient’s feeling of stability
 increases in a calm and non-
-Accept patient’s defenses; threatening environment.
do not dare, argue, or debate. - If defenses are not threatened,
the patient may feel secure and
protected enough to look at
- Converse using a simple behavior.
language and brief - When experiencing moderate
statements. to severe anxiety, patients may
be unable to understand
anything more than simple,
clear, and brief instruction.
- Reinforce patient’s - Talking or otherwise
personal reaction to or expressing feelings sometimes
expression of pain, reduces anxiety.
discomfort, or threats to
well-being (e.g., talking,
crying, walking, other
physical or nonverbal
expressions).
- Lessen sensory stimuli by
keeping a quiet and peaceful - Anxiety may intensify to a
environment; keep panic state with excessive
“threatening” equipment out conversation, noise, and
of sight. equipment around the patient.
increasing anxiety may become
frightening to the patient and
- Help patient determine others.
precipitants of anxiety that - Obtaining insight allows the
may indicate interventions. patient to reevaluate the threat
or identify new ways to deal
- Allow patient to talk about with it.
anxious feelings and - Talking about anxiety-
examine anxiety-provoking producing situations and
situations if they are anxious feeling can help the
identifiable. patient perceive the situation
realistically and recognize
factors leading to the anxious
feelings.
 - If the situational response
is rational, use empathy to
encourage patient to interpret
the anxiety symptoms as
normal.
- Provide massage and
backrubs for patient to
reduce anxiety.
- Provide patients with a
means to listen to music of
their choice.
- Educate patient and family
about the symptoms of
anxiety.
- Teach patient to visualize
or fantasize about the
absence of anxiety or pain,
successful experience of the
situation, resolution of
conflict, or outcome of
procedure.
- Teach use of appropriate
community resources in
emergency situations (e.g.,
suicidal thoughts), such as
hotlines, emergency rooms,
law enforcement, and
judicial systems.
References and Sources
Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.
Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins.
- Anxiety is a normal response
to actual or perceived danger.
- This aids in reduction in
anxiety.
- Music is a simple,
inexpensive, esthetically
pleasing means of alleviating
anxiety.
- If patient and family can
identify anxious responses, they
can intervene earlier than
otherwise.
- Use of guided imagery has
been useful for reducing
anxiety.
- The method
of suicide prevention found to
be most effective is a
systematic, direct-screening
procedure that has a high
potential for institutionalization.