21 COGNITIVEDISORDERS 519
NURSING CARE PLAN DELIRIUM
Nursing Diagnosis
➤Acute Confusion
Abrupt onset of a cluster of global, transient changes and disturbances in attention,
cognition, psychomotor activity, level of consciousness, and/or sleep/wake cycle.ASSESSMENTDATA
- Poor judgment
- Cognitive impairment
- Impaired memory
- Lack of or limited insight
- Loss of personal control
- Inability to perceive harm
- Illusions
- Hallucinations
- Mood swings
EXPECTEDOUTCOMES
Immediate
The client will- Engage in a trust relationship with
staff and caregiver - Be free of injury
- Increase reality contact
- Cooperate with treatment
Stabilization
The client will - Establish or follow a routine for
activities of daily living - Demonstrate decreased confusion,
illusions, or hallucinations - Experience minimal distress related
to confusion - Verbally recognize symptoms or
validate perceptions with staff or
caregiver before taking action
Community
The client will - Return to optimal level of functioning
- Manage chronic health conditions, if
any, effectively - Seek medical treatment as needed
IMPLEMENTATION
Nursing Interventions *denotes collaborative interventions Rationale
The client’s safety is a priority. He or she may be
unable to discriminate accurately potentially
harmful actions or situations.Do not allow the client to assume responsibility
for decisions or actions if he or she is unsafe.
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