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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

ACUTE CONFUSION Nursing Care Plan

Mrs. Lorna was admitted in the hospital due to a car accident. Even though she survived she lost her vision in that accident because of a piece of broken glass hit her eyes during the car to van impact. Since she came in a wealthy family, she immediately undergone to the surgery in her eye where in she got a donor to replace her lost vision. It took 6 hours of operation and 3 weeks of recovery for her new eyes to open up again. Although she was not yet fully recovered and her vision was still blurry, the surgery was a complete success and she can fully see again in no time. 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 of Mrs. Lorna. Too much alcohol intake can make her hallucinate and do inappropriate responses. If Mrs. Lorna 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 to Mrs. Lorna, you must evaluate her vital signs for indicators of poor tissue perfusion. Lack of oxygen in the brain also cause her hallucinations. You must also assess her diet and nutritional status of Mrs. Lorna, so that you can identify her deficiency of essential vitamins and nutrients which may cause her confusion.

- Orient Mrs. Lorna to surroundings, staffs and necessary things needed, you must concisely and briefly presents reality and give only simple directions. You allow sufficient time for Mrs. Lorna to respond, communicate and make decisions. If possible, encourage 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 Mrs. Lorna in exacerbation of her psychiatric conditions. Note her behavior that may be indicative of potential for violence and take appropriate actions. Note: Limit use of restraints because it may worsen the situation and it may increase likelihood of her 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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For more samples of nursing care plan you are free to check it out in our NCP LIST page.

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