Psych Nursing Care Plan
Anxiety r/t perceived threat to physical being as evidenced by insomnia, lack of concentration, not eating, restlessness, pulse range of 118-182, verbalized feelings of worry/phone tapped/”ER tried to kill me”/”meds tried to kill me”

Patient Outcome: Patient will return to 8 hr. nocturnal sleep pattern, eat 3 meals/day, verbalize feeling less worried, maintain focus, and maintain relaxed posture by discharge on 3/12/12.
Interventions:
-Assess patient’s level of anxiety by EOS 3/6/12. Rationale: Patient’s anxiety level can affect ADL’s, judgment, compliance, and overall safety. Patient response: Patient’s level of anxiety is severe. Not eating, calling mother excessively, verbalized many feelings of worry, driving up and down streets, crawled into bed with mother in the middle of the night. Patient stated “am I going to be in trouble?” as she is worried the cops will be after her.
-Use simple language and brief statements when instructing patient about self-care measures, anxiety medications, and orienting to unit throughout admission. Rationale: Using simple words will not overwhelm the client or increase her anxiety. Patient response: Patient verbalized she understood the rules of the unit.
-Administer Vistaril 50 mg PO QID for anxiety as ordered by physician. Rationale: Vistaril is an antihistamine used to reduce anxiety, as it slows the CNS. Patient response: Patient is worried medications will kill her, further teaching is necessary.
-Teach patient forms of relaxation techniques including slow deep breathing, meditation, yoga, listening to soft music by EOS 3/6/12. Rationale: Relaxation techniques may benefit client while in unit and upon discharge to help relax her when feelings of anxiety arise. Patient response: Patient was extremely anxious, at this time she could not focus on attempting any of the mentioned techniques.