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ACUTE CONFUSION Nursing Care Plan

Acute confusion is a state in which a person's cognitive function is below from a previously attained baseline level of cognitive function. A person with disturbance to its thought process accompany with decrease in level of conciousness is experiencing acute confusion. We provide an example of nursing care plan for acute confusion with a 3-hour nursing care intervention. 

ASSESSMENT
Subjective:
"I hear a voice of a little boy and a ball dribbling," as verbalized by the patient.

Objectives:
I observed from the patient that he/she is experiencing restlessness; a person who doesn't able to relax or rest. The decreased in level of conciousness and inappropriate responses are clearly manifested. I also noticed that there is poor eye contact and fluctuation in his/her body movement.

The vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius which is above normal level of 36.5, blood pressure is 110/80 mmHg which is considered normal, pulse rate of 85 bpm and respiratory rate of 18 cycle per minute. Both pulse rate and respiratory rate are normal.

DIAGNOSIS
(You may use "Acute confusion related to acoustic hallucination as manifested by strategic level of consciousness and inappropriate responses.") Acoustic hallucination refers when a person is hearing a sound or void that seems real to them but does not really exist. The patient verbally said that he/she is hearing a voice of a little boy and a ball dribbling which is actually not exist in his/her room.

PLANNING
After 3 hours of nursing intervention, the patient will regain usual reality, orientation and level of consciousness. (Why 3u hours? Actually, it depends on how much time you would take to accomplish all your actions and interventions to manage the patient's problem).

INTERVENTION
Before anything, you must first investigate the possibility of alcohol and other drug withdrawal or intake. Too much alcohol intake can make a person hallucinate and do inappropriate responses. If the patient was drunk, make a plan for acute confusion due to alcohol intake. Drug withdrawal or intake, like alcohol, could also cause hallucinations.

After investigation had done, you must evaluate vital signs for indicators of poor tissue perfusion. Lack of oxygen in the brain also cause hallucinations. You must also assess the diet and nutritional status of the patient, so that you can identify the deficiency of essential vitamins and nutrients which may cause confusion.

Orient the client to surroundings, staffs and necessary things needed, you must concisely and briefly presents reality and give only simple directions. You allow sufficient time for the client to respond, communicate and make decisions. If possible, encourage his/her family members to participate in the reorientation as well as providing out aping input. While doing this, you must maintain calm environment and eliminate extraneous stimuli to prevent exacerbation of psychiatric conditions. Note behavior that may be indicative of potential for violence and take appropriate actions. Note: Limit use of restraints because it may wooden the situation and it may increase likelihood of untoward complications.

EVALUATION
After 3 hours of nursing intervention, the patient regained usual reality, orientation and level of consciousness. (Remember that this is your goal, if the patient still experiencing the problem, try to reassess the patient again.

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