NANDA-Nursing Plan 00128 Acute confusion

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 5 Perception/Cognition
Human processing systems, including attention, orientation, sensation, perception, cognition, and communication
Class 4 Cognition Memory, Learning, Thinking, Problem Solving, Abstraction, Judgment, Insight, Intellectual Ability, Computation, Use of Language

00128 Acute confusion

Nursing Diagnosis: 00128 Acute confusion
Definition: reversible disturbances of consciousness, attention, cognition, or perception of duration less than 3 months

Thank you for always watching m(_ _)m
This time, I’m going to think about acute confusion, but before that, what is “confusion”?
What is the difference between “confusion” and “delirium” and “disturbance”?
Am I the only one with such doubts?
Let’s take a look at each definition and think about it.

1. The difference between “confusion,” “delirium,” and “disturbance”

Let’s put “confusion” on the back burner and start with “delirium” and “disturbance”.

1) delirium

“Delirium” is a diagnostic name.
(1) Definition:
A state in which communication becomes temporarily difficult due to mild disturbance of consciousness, excitement, and perceptual disturbance (hallucination, delusion, illusion).
The key points here are “transient” and “disturbance of consciousness.”
(2) Mode of onset:
Onset occurs in a few hours to a few days, with diurnal fluctuations. Many at night.
(3) Cause:
① Preparatory factors: dementia, cerebrovascular disease, hypertension, diabetes, old age
②) Promoting factors: hospitalization/ICU, surgery, postoperative pain, continuous infusion, rodents such as urinary catheters,
Dark place, lack of sleep, physical restraint, anxiety
③ Direct factors: drugs (sleeping pills, etc.), alcohol, metabolic abnormalities, electrolyte abnormalities, hypoxemia,
Hypercapnia, infection, cerebrovascular disease, head injury, dehydration, liver dysfunction, renal dysfunction
・Removal of causes and triggers
Antipsychotics for severe delirium (hallucinations and agitation)

2) Unrest

(1) Definition:
in the Goo dictionary
It is introduced as “not calm. The situation is unstable and fraught with danger and danger.”
While “delirium” is a diagnosis, “restlessness” is a term that describes the “state”, “symptoms”, and “behavior” that a patient is exhibiting.
Unlike delirium, restlessness does not accompany “disturbance of consciousness (disorientation/memory impairment).”

(2) Specific symptoms of restlessness
・ Restless
・Self-removal of drips, etc.
(3) Cause of unrest
Delirium (restlessness due to delirium)

3) confusion

(1) Definition:
confusion is to be perplexed
・Unclear, ambiguous
・Confusion, mix-up
・Confusion, chaos
・ bewildered, perplexed, bewildered

Looking at the “related factors”, “high risk group” and “related conditions” of the nursing diagnosis “acute confusion”,
Includes “history of cerebrovascular accident”, “dehydration”, “physical restraint”, “decreased level of consciousness”, etc.
Overlaps requirements to meet delirium.
I think that this “confusion” can be thought of in a sense similar to “delirium”.
In addition, in the NOC linkage, the outcome indicator of “acute confusion” includes “level of delirium”.
The addition of “acute” emphasizes that it is “temporary”. However, according to the definition of delirium, it is premised that delirium itself is “temporary, transitory”, so it is not called acute delirium. Think of it as “acute confusion ≒ delirium”.
Delirium is also classified as hypoactive delirium. This is the case when the person is disorientated or has memory problems but is calm and does not exhibit dangerous behavior. This time’s “acute confusion” is planned with the image of active delirium, not hypoactive delirium.
Clinically, delirium is often seen after surgery and in the elderly. It’s easy to use medicine or suppress it, but they are the last resort. It’s best to start by doing what you can do, such as increasing activity during the day and building relationships to help your child get used to the environment.

2. subject to acute confusion

Since “acute confusion” is a real diagnosis, it is intended for people who already have the following symptoms.
・Consciousness disorder (disorientation/memory disorder)
・Excited (loud, talkative, swearing, etc.)
・Perceptual disturbances (hallucinations, delusions, illusions)
・There is restlessness (restlessness)
・Dangerous behavior such as voluntarily withdrawing the IV and trying to climb over the fence.
・Transient difficulty in communication

3. aim setting

1) Indicators based on linkage

・Level of delirium (0916)
(Definition: severity of short-term, reversible impairment of consciousness and cognition)
・Orientation (0901)
(Definition: Ability to accurately recognize people, places and times)
・Cognition (0900)
(Definition: complex mental processes)
– Excitement level (1214)
(Definition: severity of disruptive physiological and behavioral signs of stress or biochemical triggers)
adaptation of behavioral responses)
・Sleep (0004)
(Definition: Natural and periodic cessation of consciousness with physical recovery)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・There is no reversal of day and night, ensuring sufficient sleep at night.

・You can create your own calm living environment (recuperative environment).

・I can talk about my anxiety.

・ You can take medicine as prescribed by your doctor.

*Nurse goals include:

・Provide a safe environment.

• Help reduce the frequency of delirium.

3. nursing plan

1) Observation plan 《OP》

(1) Things that cause delirium
①Preparation factor (originally has a predisposition)
・Cerebrovascular disease (cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage)
・Brain tumor
・Head injury
・High blood pressure
② Facilitating factors (indirect causes that induce delirium)
・ICU management
・Continuous infusion ・Bruce such as urinary catheter
・dark place
・Lack of sleep
・Body restraint
③ Direct factor (direct cause of delirium)
・Drugs (sleeping pills, etc.)
・Metabolic abnormalities (thyroid dysfunction, adrenal cortical dysfunction, pituitary dysfunction)
・Electrolyte abnormality
・Liver dysfunction
・renal dysfunction

(2) Physical condition
・vital signs
・Level of consciousness, memory impairment, disorientation
・History of delirium
・hallucinations, delusions
・Cognitive impairment (Hasegawa score of 20 or less, MMSE score of 21 or less)
・Disease: Cerebrovascular disease, brain tumor, brain trauma
・Treatment course of the disease
・Treatment content
・Current medical care environment (ICU, distance from nurse station, multi-bed room)
・The location and degree of pain, and the use of analgesics
・Nursing care level
・Balancing sleep and activity
・Insomnia (noise, frequent urination, environmental changes, etc.)
・Activity/living area (only around the bed, only indoors, etc.)
・Negative behavior, lethargy, anxiety
・Possibility of meeting
・ Whether there is a familiar person (doctor, nurse, rehabilitation, SW, etc.)

2) Action plan 《TP》

Eliminate causes and inducements.
①Environmental improvement
・Create a calm environment that is quiet and not too bright. (The sound of the monitor may cause delirium.)
・If you cannot take your eyes off the patient due to self-extraction or climbing over a fence, move to a room closer to the nurse station until the patient calms down.
・Have familiar items (watches, small items, etc.) brought and arranged.
・Provide an opportunity to meet the family at a visitation.
・Visit the room as often as possible (even if it’s just a peek, don’t leave it alone).
② Removal of cause
・If there is a disease that is the direct cause, follow the treatment plan and provide assistance with meals, medication, etc. under the direction of a doctor.
・If restraint is the cause, examine the validity of restraint.
・Make sure that pipes such as IV drips and balloon catheters are not visible (pass through the hem, wrap a bandage, etc.)
・Building relationships by snuggling and listening.
Make them understand that it is a safe environment.
If you scold or preach, it will instead cause distrust and fear, and it will have the opposite effect, so don’t do it.
If you have pain, follow your doctor’s instructions and administer an analgesic.
③ Balance between day and night
・In the daytime, put the patient in a wheelchair as much as possible or watch TV to encourage awakening and help him/her sleep at night.
• Incorporate recreational activities.
④ Record
・Record when and what kind of delirium occurred and how you dealt with it.
(Evaluate which measures were effective.)

3) Education plan 《EP》

・Tell them to consult if you have any problems.
・Tell them to eat properly and drink water appropriately.
・Tell them that you want them to accompany you during the daytime activities. (Tell the patient that it is dangerous for the patient to move alone, so he or she will accompany the patient.)
・If there is pain, tell them that it is okay to let them know without putting up with it.


T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
T. Heather Hardman, Shigemi Kamitsuru, Camila Takao Lopez. (July 1, 2021). NANDA-I Nursing Diagnosis – Definition and Classification 2021-2023 Original 12th Edition. Igaku Shoin Co., Ltd.
Linda J. Calpenito. (2014.1.1). Nursing Diagnosis Handbook. Igaku Shoin Co., Ltd.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.

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投稿者 FlorenceMYM


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