Mr. H has recently been diagnose with Lung cancer. Someone has written the nursing diagnosis of anxiety on his care plan.
1. What data/ defining characteristics would support this nursing diagnosis?
The data would support this nursing diagnosis are physiological aspects like Increase in blood pressure, pulse, and respirations, dizziness, light-headedness, perspiration, flushing. Behavioral like expressions of helplessness, Crying, Insomnia
2. Which related factors might exist in his situation?
In Mr. H situation some of the related factors are related to unfamiliar environment; lack of understanding of diagnosis, diagnostic tests, and treatments; financial concerns; and feelings of confinement. 3. Which other nursing diagnosis might you expect to find in Mr. H case? Other nursing diagnosis we might or expect to find in Mr. H case are difficulty concentrating, inability to problem-solve, palpitations, dry mouth, headaches, Nausea and/or diarrhea, Restlessness, nightmares, Trembling.
4. Another nursing diagnosis on the other care plan reads “lung cancer related to smoking”. Is this diagnosis written in an acceptable format? If not why not?
No, because this is a medical diagnosis not a nursing diagnosis.
NURSING CARE PLAN
Physiological Defining characteristics
Increase in blood pressure, pulse, and respirations
Expressions of helplessness
Feelings of inadequacy
DIAGNOSIS: ANXIETY DUE TO RECENTLY DIAGNOSE PATIENT WITH LUNG CANCER
Note palpitations, elevated pulse/respiratory rate.
Changes in vital signs may suggest the degree of anxiety patient is experiencing or reflect the impact of physiological factors,
Identify client’s perceptions of the situation
Orientation and awareness of the surroundings promotes comforts and may decrease anxiety Maintain frequent contact with client/SO. Be available for listening and talking as needed. Establishes rapport, promotes expression of feelings, and helps client and SO look at realities of the illness/treatment without confronting issues they are not ready to deal with. Stay with or arrange to have someone stay with client as indicated Continuous support may help client regain internal locus of control and reduce anxiety/fear to a manageable level Avoid empty reassurances, with statements of “everything will be all right.” Instead, provide specific information: e.g., “Your heart rate is regular, your pain is being easily controlled, and that is what we want” It is not possible for the nurse to know how the specific situation will be resolved, and false reassurances may be interpreted as lack of understanding or honesty, further isolating client. Sharing observations used in assessing condition/prognosis provides opportunity for client/SO to feel reassured.
Encourage client to develop regular exercise/activity program Helpful in reducing level of anxiety; has been shown to raise endorphin levels to enhance sense of well-being Document behavioral and verbal expressions of fear.
Physiological symptoms and/or complaints will intensify as the level of fear increases. Note that fear differs from anxiety in that it is a response to a recognized and usually external threat. Manifestations of fear are similar to those of anxiety
• Identify time alone and time needed with others.
• Communicate important thoughts and feelings to family members. • Obtain the level of spiritual support desired.
• Use available support systems.
• Perform self-care activities to tolerance level.
• Express feelings of comfort and peacefulness.
RITCHEL L. DEOCAMPO
BSN- 1ST YEAR