SANTOS, IVAN JAMIL S.

NCM 112- OR RLE

Fear (Pre-Op)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:  Fear evidenced by Short Term Goal: Independent Short Term Goal:
 “Pwede naman decrease in self- After 8 hours of >> Compare verbal to >> The client may be After 8 hours of nursing
sigurong gamutin assurance and nursing interventions, nonverbal responses to able to verbalize what interventions, patient has
nalang ano? Kahit increase in tension the client will: note congruencies or he or she is afraid of, if visualized:
wala nang secondary to  Acknowledge and misperceptions of the asked, providing  Acknowledged and
surgery” as Cholecystectomy discuss fears, situation. opportunity to address discussed fears,
verbalized by the surgery recognizing fears. recognizing healthy
patient healthy versus versus unhealthy fears.
>> Assess family >> Actions and
unhealthy fears. Goal was Met
dynamics. responses of family
 Verbalize accurate
Objective: members may
knowledge of and  Verbalized accurate
 Fidgeting exacerbate or soothe
sense of safety knowledge of and
 Muscle tension fears of the client.
related to current sense of safety related
 Increase in
situation. >> Provide information >> This facilitates to current situation.
alertness
 Display lessened in verbal and written understanding and Goal was Met
 Avoidance
fear as evidenced forms. Speak in simple retention of information.
behaviors
by appropriate sentences and concrete  Displayed lessened fear
 Focus narrowed
range of feelings terms. as evidenced by
to the source of
and relief of appropriate range of
fear >> Modify procedures if >> To limit the degree
signs/symptoms. feelings and relief of
 Increase in possible. of stress and avoid
signs/symptoms.
perspiration overwhelming a fearful
Goal was Met
 Vital Signs individual.
T: 36.2ºC
>> Encourage contact >> This provides a role  Vital Signs
HR: 120 bpm
with a peer who has model, and the client is T: 36.3 ºC
RR: 21 bpm
successfully dealt with a more likely to believe HR: 81 bpm
BP: 115/80
similarly fearful situation. others who have had RR: 18 bpm
mmHg
similar experiences. BP: 115/80 mmHg
SpO2: 98%
SpO2: 98%
>> Assist client with >> This may enhance
relaxation, visualization, coping skills, allowing
and guided imagery skills. the body to reduce fear
and anxiety.