Question

. The nurse is developing a nursing care plan for a patient with anxiety. Utilize the nursing process when creating a care plan.

Patient states that he has not slept in two days, has been drinking more frequently at the local bar, and he lives alone. The patient appears restless with tremors, diaphoretic, pale, and speaks with a trembling voice.

Vital signs: T- 99.1, HR- 114, RR- 24, BP- 131/67 and O2 sat is 92% on room air.

• Address the assessment of the patient
• Develop two NANDA nursing diagnoses (one actual and one potential/at risk)
• Have two outcomes/goals (one for each nursing diagnosis)
• List two independent nursing interventions for each outcome (total of four interventions)
• Have one expected evaluation for each outcome/goal.

Answer 1

●Nursing Diagnosis

Disturbed sleep pattern related to anxiety ,restlessness as evidenced by verbalisation

Assessment

Subjective :

• Didn't sleep in last 2 days
• Loneliness

Objective data:

• Restless
• Trembling voice
• Pale
• Tachycardia
• Tachypnea

Outcome

• Able to have a good sleep pattern
• Feeling energetic after a good sleep physically and mentally in the daytime

Nursing interventions

• Provide psychological support,counseling, talk therapy to come out with the problems and provide solutions to relieve nervousness and encourage sleep
• Administer anti anxiety or sleeping pills as per order to encourage sleep
• Provide a calm and quiet environment to induce sleep
• Avoid alcohol because this may interrupt sleep and cause tiredness the consecutive day
• Sleep study can be done to find underlying cause for insomnia

Evaluation

The patient had a good sleep pattern

●Nursing Diagnosis

Risk for substance abuse (alcohol)/ liver injury related to excessive drinking as evidenced by verbalisation, tremors, nervous,,trembling voice

Assessment

Subjective data

• Drinking more frequently

Objective data

• Anxiety
• Nervous
• Changes in vital signs

Outcome

• To relieve from drinking
• Participate in social activities
• Diaphoretic

Nursing intervention

• Encourage the patient substance abuse treatment program to reduce its desire
• Health educate on the harmful effects on the body
• Provide support therapy to avoid being lonely and thus prevent drinking
• Encourage patient to take fluids as alcohol can cause the body to deprive of water after a short phase of diaphoresis

Evaluation

The patient is actively engaged in the community

Patient avoids drinking alcohol