Medical Diagnoses: Acute Confusion; Delirium, patient over 60 years of age.

Assessment Nursing Client Goals/Desired Nursing *I Evaluation

DX/Clinical Outcomes/Objectives Interventions/Actions/Orders Goals Interventions
Problem and Rationale
Subjective: Problem Long Term: Assess the client's behavior and Unable to Unable to evaluate-
Unable to Acute Client will cognition systematically and evaluate- did not did not care for
attain- did Confusion demonstrate continually throughout the day care for patient. patient.
not assess the optimization of and night, as
patient. cognitive status to base appropriate. EB: Rapid onset
line by the time patient and fluctuating course are
is dishcharged. hallmarks of delirium
(Murphy, 2000; Inouye, 2006).
The Confusion Assessment
Method (CAM) is sensitive,
specific, reliable, and easy to
Objective use. Another tool to consider is
Unable to the Mini-Mental State
attain- did Examination (Inouye, 2006). It
not assess the is necessary to pay attention to
patient. behavioral changes because
recent research has shown that
there may be a prodromal
phase of delirium in which
sudden disorientation and
urgent calls for attention may
precede the onset of delirium
(Duppils & Wikblad, 2004).
R/T Short Term: Provide supportive nursing Unable to Unable to evaluate-
Delirium, Client will optimize care including meeting of basic evaluate- did not did not care for
patient over hydration and needs such as feeding, toileting, care for patient. patient.
60 years of nutrition by discharge. and hydration. EBN:Delirious
age. clients are unable to care for
themselves due to their
confusion. Their care and
safety needs must be
anticipated by the nurse
(Foreman et al, 1999).