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Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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Subjective
Patient states that the family just moved
from xxxxx to xxxxx.
“We lost our house in a hurricane.”
“I am unemployed and my husband’s income
is not reliable.”
“I am pregnant with four other children.”
“We only have one car.”
Objective
Recent move,
experience
of natural disaster, pregnant, client
unemployed, anxious tendencies (fidgeting and increased perspiration)
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Problem
Anxiety
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Long Term:
Family will verbalize absence of
or decrease in subjective distress by xxxxxx measured by family’s word.
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Guided imagery can be used to decrease anxiety. Rationale:
Anxiety was decreased with the use of guided imagery (Antall & Kresevic, 2004).
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Provide clients with a means to listen to music of their choice or audiotapes. Provide
a quiet place and encourage clients to listen for 20 minutes. Rationale:
Music listening reduces anxiety and pain (McCaffrey & Locsin, 2006).
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R/T
economic status, environment, health status, interaction patterns, role function,
role status
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Short Term:
Family will identify and verbalize
a minimum of five symptoms of anxiety by 11.01.09 measured by family’s word.
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If the situational response is rational, use empathy
to encourage the client to interpret the anxiety symptoms as normal. Rationale:
Enhancing self-esteem and providing information and psychological support promotes
stess and anxiety (Alasad & Ahmad, 2005).
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Assess for the presence of culture-bound anxiety states.
Rationale:
The way anxiety is shown is effected bb the culture
(Emery, 2006;
Kuipers, 2004).
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Identify how anxiety is manifested in the culturally
diverse client. Rationale: Anxiety
is manifested differently from culture to culture (Kisely & Simon, 2006).
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