ASSESSME DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

NT
Subjective Risk for After two hours of nursing  Assess mental 1. typical symptoms After two hours of nursing
“Why am I acute intervention the patient status of delirium intervention the patient:
here what confusion will: include anxiety,  Regained and
happened related to  Regain and disorientation, maintained usual
to me? pain. maintain usual tremors, reality orientation
Why does Explanation: reality orientation hallucinations, and level of
my head During the and level of delusions and consciousness
hurts so admission, consciousness incoherence.  Verbalized
bad?”, as the patient  Verbalize Onset is usually understanding of
verbalized is confuse. understanding of sudden, causative factors
by patient. Reversible causative factors developing over a or risk factors and
disturbances or risk factors few hours or Initiate lifestyle or
Objective of when known.  Evaluate vital sign days, and behavior changes
-Agitation consciousne  Initiate lifestyle or resolving over to prevent or
-stiff neck ss, behavior changes varying periods of reduce risk of
-Inability to attention, to prevent or time. problem.
initiate cognition, reduce risk of 2. For indicators of  Initiated lifestyle
goal- and problem.  Assess diet and poor tissue or behavior
directed or perception nutritional status. perfusion (i.e., changes to
purposeful that develop hypotension, prevent or reduce
behavior. over a short tachycardia or risk of problem.
period of tachypnea) or
time.  Determine the stress response
client’s functional (tachycardia
level, including tachypnea).
the ability to 3. to identify
provide self-care possible
and move about deficiencies of
will. essential
nutrients and
vitamins (e.g.,
thiamine) that
 could affect
mental status
4. conditions and
situations that
limit a client’s
mobility and
independence
[acute or chronic
physical or
psychiatric
 Monitor/adjust illnesses and their
medications therapies, trauma
regimen and note or extensive
response. immobility,
confinement in
unfamiliar
surroundings and
 Provide adequate sensory
supervision: deprivation]
remove harmful potentiate the
objects from prospect of acute
environment, confusional state.
provide siderails
and seizure
precautions, place 5. When
call bell and polypharmacy,
position needed side effects or
items within adverse reactions
reach, clear traffic are determined
paths and to be associated
ambulate with with current
devices. condition.
 Orient client to 6. to meet clients
surroundings, safety needs and
staff, necessary reduce risk of
activities, as falls
needed. Present
reality concisely
and briefly.

7. to avoid
defensive
reactions.