- Acute confusion related to medication side effects, sleep deprivation, older age as evidenced by hallucinations, fluctuations in cognition
- Impaired social interaction related to impaired cognitive functioning and altered thought processes as evidenced by consistent state of disorientation to environment and dysfunctional interaction with others
- Risk for Injury related to changes in cognitive function and unfamiliar environment as evidenced by signs and symptoms.
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
Subjective Data: Hallucinations Paranoia Objective Data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute confusion related to medication side effects, sleep deprivation, older age as evidenced by hallucinations, fluctuations in cognition | Patient will demonstrate appropriate orientation to person and place. Patient will cooperate with care and assessments. Patient will communicate needs and follow commands. | 1. Reorient the patient as needed. Help to maintain reality and prevent anxiety by orienting to place and time as needed. 2. Provide familiar objects. Pictures of family members or a favorite blanket may assist in keeping the patient calm and aware. 3. Remain calm and comforting. Use a calm, reassuring voice and provide touch as long as it doesn’t agitate the patient. Avoid arguing with the patient who is confused. 4. Treat the underlying cause. An infection may require antibiotics. Severe pain can be treated with opioids. Alcohol withdrawal is treated with anti-anxiety medications. Dehydration requires fluid resuscitation and supplemental electrolytes. | Patient regained orientation to person, place, time, and situation with an appropriate level of consciousness. Patient initiated lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient verbalized contributing factors of fluctuations in cognition. |
Subjective Data: Expressed violent and aggressive behavior Objective Data: -Consistent state of disorientation to environment -Extreme confusion -Slow/inappropriate response to questions -Dysfunctional interaction with others -Inability to focus -Agitated behavior -Drowsiness | Impaired social interaction related to impaired cognitive functioning and altered thought processes as evidenced by consistent state of disorientation to environment and dysfunctional interaction with others | Patient will respond appropriately to questions. Patient will participate in a group setting within their capabilities. | 1. Ensure that medications are taken as prescribed. Some patients may not take medications correctly, either overdosing or underdosing. 2. Provide a calm environment. Allow the patient to interact with familiar faces by providing an isolated, quiet, and nonstimulating environment. 3. Maintain routines and staff assignments. Maintaining similar routines, such as eating and bathing schedules, can enhance orientation. If possible, keep the same staff members with the patient to promote communication and trust. 4. Differentiate between delirium and dementia. Delirium and dementia can occur together or separately, as dementia makes the brain more susceptible to delirium. Delirium is temporary, while dementia is chronic. | Patient responded appropriately to questions. Patient participated in a group setting within their capabilities. |
Subjective Data: Expresses behaviours to harm himself Objective Data: -Changes in cognitive function -Disorientation, confusion -Unfamiliar environment -Self Harm | Risk for Injury related to changes in cognitive function and unfamiliar environment as evidenced by signs and symptoms. | Patient’s family will implement strategies to reduce the risk of injury. Patient will remain free of injury. | 1. Remain with the patient when agitated or combative. Staff may need to remain at a distance to prevent injury to themselves, but remaining at the bedside may be necessary to prevent the patient from injuring themselves. Restraints are considered as a last resort. 2. Familiarize them with their environment. Hospitalization, especially for long durations or associated with surgery or ICU admission, increases the incidence of delirium. Familiarize the patient with their environment and advise on how to call for assistance. 3. Keep items in close reach. Eyeglasses and hearing aids should be kept close as poor vision and hearing can worsen confusion. 4. Administer antipsychotics. Patients who are severely combative or uncooperative may require IV or IM medications to induce sedation. Haloperidol is a common medication given to agitated patients to reduce the risk of harm to themselves and others. | Patient remained free from falls. Patient will engage in safe behavior and take action to reduce chance of injury. Patient remained free from any form of self-harm. Patient remained free from any skin breakdown or impairment in skin integrity. |