Republic of the Philippines
NEGROS ORIENTAL STATE UNIVERSITY
ARCES, MARDIE M.
BSN IV
ASSESSMENT
Subjective data:
Patient verbalized:
 “It’s like climbing a set of
stairs, so you go 1, 2, 3,
and then there’s no steps,
and somehow you have to
get from the first step to
the tenth one.”
 “Trauma changed me
drastically, fragmented me
and everything around
me.”
 “I didn’t recognize my
writing. I found clothing
that wasn’t mine in my
wardrobe. Losing time was
one of the biggest
problems for me.”
 “I just thought I was going
insane.”
 “I’m physically tired. I’m
emotionally tired. I’m
socially tired. Yeah, I’m
exhausted.”
Founded 1907
Dumaguete, Bais, Guihulngan, Mabinay, Pamplona, Siaton and Bayawan-Sta. Catalina
DIAGNOSIS
Acute Confusion related to
mental illness (Dissociative
Identity Disorder)
RA 9299
COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES
PLANNING
At the end of quality nursing
interventions, the patient will
initiate lifestyle or behavior
changes to prevent or reduce
risk of problem as evidenced
by:
 Being calm
 Being well rested
 Absence of stress
 Minimize crying
INTERVENTION
Independent:
1. Identify factors present
such as traumatic events.
2. Evaluate vital signs.
3. Determine the client’s
functional level, including
the ability to provide self-
care and move about at
will.
4. Explain reason(s) for
confusion, if known.
RATIONALE EVALUATION
At the end of quality nursing
Acute confusion is a symptom interventions, the patient
associated with numerous initiated lifestyle or behavior
causes. changes to prevent or reduce
risk of problem as evidenced
For indicators of poor tissue by:
perfusion or stress response.
 Being calm
Conditions and situations that  Being well rested
limit a client’s mobility and  Absence of stress
independence (e.g., acute or  Minimized crying
chronic physical or psychiatric
illnesses and their therapies;
trauma or extensive
immobility, confinement in
unfamiliar surroundings, and
sensory deprivation)
potentiate the prospect of
acute confusional state.
Although acute confusion
usually subsides over time as
the client recovers from the
underlying cause and/or
 Republic of the Philippines Founded 1907 RA 9299
NEGROS ORIENTAL STATE UNIVERSITY
Dumaguete, Bais, Guihulngan, Mabinay, Pamplona, Siaton and Bayawan-Sta. Catalina
COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES
Objective data:
 Restlessness
 Exhausted
 Stressed
 Crying
5. Orient client to
surroundings, staff, and
necessary activities, as
needed. Present reality
concisely and briefly.
Avoid challenging illogical
thinking
Dependent:
1. Administer psychotropics
cautiously
Collaborative:
1. Collaborate with medical
and psychiatric providers.
Review results of
diagnostic studies.
adjusts to a situation, it can
initially be frightening to a
client/SO. Therefore,
information about the cause
and appropriate treatment to
improve the condition may be
helpful in managing a sense
of fear and powerlessness.
Defensive reactions may
result.
To control restlessness,
agitation, and hallucinations.
To evaluate the extent of
impairment in orientation,
attention span, ability to
follow directions, send and
receive communication, and
appropriateness of response.