Date/Time

7/16/15

Cues
Subj:

@8am

unsa diay
na nga mga
tambal
nasad as
verbalized
by mother
daghana
diay
kailangan
buhaton
para sa
procedure
no? as
verbalized
by the
mother
hadlok ni
syag
nakaputi as
verbalized
by mother
Obj:
-age of
4years

Need
selfperception
;
selfconcept
pattern

Nsg. Diagnosis
Anxiety r/t
intrusive
surgical
procedures s/t
uteroneocystost
omy for removal
of Ureteropelvic
Junction
Obstruction
stenosis

Nsg. Objectives
That within my 4
hour span of care
the client and his
mother will be able
to have a sense of
calm and relief AEB
A. Relaxed
appearance
B. Verbalization
of relief from
the client or
parent
C. Client is able
to calmly
stay in bed or
by bedside

Interventions
1. Inform
patient or SO
of nurses
intraoperativ
e advocate
role.
R- Develops
trust and
rapport,
decreasing
fear of loss
of control in
a foreign
environment.
2. Identify
fear levels
that may
necessitate
postponeme
nt of surgical
procedure.
ROverwhelmin
g or
persistent
fears result
in excessive
stress
reaction,
potentiating

Evaluation
@ 7/16/15
@ 12nn
Goal met
Patient and
watcher were
visibly more
relaxed and
showed relief AEB
A. client
maintained
a relaxed
appearance
B. ahhh ok
ana diay na
kasabot
nako ngano
kailangan
daghan
buhatunu-n
jud
As
verbalized
by the
mother
C. Observable
calmness of
client and
watcher

-visible
changes in
behavior
upon
interaction
with
medical
professional
s or nursing
students

risk of
adverse
reaction to
procedure
and/or
anesthetic
agents.
3. Validate
source of
fear. Provide
accurate
factual
information.
RIdentification
of specific
fear helps
patient and
watcher deal
realistically
with it.
4. Note
expressions
of distress
and feelings
of
helplessness
,
preoccupatio
n with
anticipated

change or
loss, choked
feelings.
R- Patient
may already
be grieving
for the loss
represented
by the
anticipated
surgical
procedure,
diagnosis or
prognosis of
illness.
5.Assess
patients age
and level of
capacity for
understandin
g
R-in order to
properly
assess how
appropriate
interventions
and
explanations
are.
6. Introduce
staff at time

of transfer to
operating
suite.
REstablishes
rapport and
psychologica
l comfort.
7. Control
external
stimuli.
RExtraneous
noises and
commotion
may
accelerate
anxiety.
8. Refer to
pastoral
spiritual
care,
psychiatric
nurse,
clinical
specialist,
psychiatric
counseling if
indicated.
R- May be
desired or

required for
patient to
deal with
fear,
especially
concerning
lifethreatening
conditions,
serious
and/or highrisk
procedures.
9.Avoid
medical
terms or
jargon and
provide
simple
explanations
appropriate
for the client
and watcher
R-to help
ease anxiety
and prevent
further
confusion
about the
situation
10.Provide

privacy to
the client, go
inside the
room only
when
implicated
R-to provide
a sense of
security,
privacy and
to avoid the
client being
overwhelme
d