Nursing Care Plan


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Medical Diagnoses: Acute Confusion; Delirium, patient over 60 years of age.

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Unable to attain- did not assess the patient.

     

     

     

     

     

     

Objective

Unable to attain- did not assess the patient.



Problem

Acute Confusion

    

    

 

Long Term:

Client will demonstrate optimization of cognitive status to base line by the time patient is dishcharged.

Assess the client's behavior and cognition systematically and continually throughout the day and night, as appropriate. EB: Rapid onset and fluctuating course are hallmarks of delirium (Murphy, 2000; Inouye, 2006). The Confusion Assessment Method (CAM) is sensitive, specific, reliable, and easy to use. Another tool to consider is the Mini-Mental State Examination (Inouye, 2006). It is necessary to pay attention to behavioral changes because recent research has shown that there may be a prodromal phase of delirium in which sudden disorientation and urgent calls for attention may precede the onset of delirium (Duppils & Wikblad, 2004).

    

Unable to evaluate- did not care for patient.



Unable to evaluate- did not care for patient.

R/T

Delirium, patient over 60 years of age.

    

    

    

    

    

Short Term:

Client will optimize hydration and nutrition by discharge.

Provide supportive nursing care including meeting of basic needs such as feeding, toileting, and hydration. EBN: Delirious clients are unable to care for themselves due to their confusion. Their care and safety needs must be anticipated by the nurse (Foreman et al, 1999).

    

Unable to evaluate- did not care for patient.



Unable to evaluate- did not care for patient.

AEB

Fluctuation in cognition and decreased level of consciousness.

    

    

    

    

    

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.



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