Risk for acute confusion

GOAL: Improved mental status; ability to cope with cognitive and behavioral changes
Expected Outcomes
Nursing Interventions
Rationale
Adheres to protein
1. Restrict protein,
1. Reduces source of
restriction.
prescribe for
ammonia
NOC Electrolyte and
transient period
2. Promotes consumption of
acid/base balance
2. Give frequent, small
adequate carbohydrates for
Indikator:
feedings of
energy requirements and
- Serum kreatini dalam
carbohydrates.
spares protein from
rentang normal
NIC Acid Base
breakdown for energy.
- Serum bikarbonat dalam Management: metabolic
rentang normal
acidosis
- Serum karbon dalam
- Memberikan
rentang normal
karohidrat dalam
frekuensi sering dan
Demonstrates an interest
sedikit
3. Minimizes risk for
in events and activities in
further increase in
environment.
metabolic requirements.
Demonstrates normal
3. Protect from
4. Minimizes shivering,
attention span.
infection.
which would increase
Follows and participates
4. Keep environment
metabolic requirements.
in conversation
warm and draft-free
appropriately.
NIC Infection protection
Is oriented to
- Perlindungan thd
person,place, and time.
proteksi
Remains in bed when
- Jaga lingkungan
indicated.
tetap hangat dan
NOC Infection severity
udaranya tepat
- Chilling
NOC Comfort status:
environment
- Diam di kasur jika
diindikasikan
- Ikuti dan partisipasi
perintah
NOC Cognitive orientation
- Mengidentifikasi
tempat, waktu, diri,
dengan benar
------------- Reports no urinary or fecal
incontinence.
Experiences no seizures.
--------------5. Pad the side rails of
bed.
No neurological or
respiratory depression.

------------------------5. Provides protection for

the patient should hepatic
coma and seizure activity
occur.
6. Minimizes patients
activity and metabolic
requirements.

 Develops no cognitive
impairments but if they
develop they are quickly
identied and treated
enhancing the potential of
recovery.
Patient and family
describe adequate
feelings of coping and
lowered anxiety. They
demonstrate ability to listen
and to make decisions as
able.
Patient and family
communicate their feelings
and their needs in a secure
and caring environment.

6. Limit visitors.

7. Provide careful
nursing surveillance
to ensure patients
safety.

8. Avoid opioids and

barbiturates.

9. Awaken at intervals
(every 24 h) to
assess cognitive
status.
10. Identify subtle changes
in behavior or sleepwake
pattern (consistent staff
caring for the patient
enhances this assessment as
they become familiar with
patients baseline).
11. Assess handwriting or
drawing skill as indication
of cognitive ability.
12. Encourage patient and
family to participate in
therapeutic strategies to
enhance coping with
episodes of mental
deterioration.
13. Encourage patient and
family to discuss feeling of
fear, powerlessness
or emotional distress related
to patients mental
deterioration.

7. Provides close
monitoring of new
symptoms and minimizes
trauma to the confused
patient.
8. Prevents masking of
symptoms of hepatic coma
and prevents drug overdose
secondary to reduced ability
of the damaged liver to
metabolize opioids and
barbiturates. Prevents
respiratory depression.
9. Provides stimulation to
the patient and opportunity
for observing the patients
level of consciousness.
10/11. These changes may
herald worsening of
encephalopathy which requires rapid intervention
including medication.

12. Promoting activities

such as listening
to music, relaxation
techniques or preillness
coping strategies can reduce
anxiety.
13. Actively listening
demonstrates caring and
concern.