Scribd
Upload
4K views2 pages

Risk For Acute Confusion

The patient is at risk for acute confusion due to an inability to detoxify ammonia and high ammonia and low sodium levels. The plan is to observe the patient for changes in behavior and mental status, review medications, note any signs of hepatic encephalopathy, consult with family about usual behavior, reorient the patient as needed, provide consistent nursing care, and discuss the situation and expectations with the patient and family. The rationale is to properly assess, treat, and evaluate the patient given the fluctuating nature of their condition and risks of progression.

Uploaded by

Char Perea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
4K views2 pages

Risk For Acute Confusion

The patient is at risk for acute confusion due to an inability to detoxify ammonia and high ammonia and low sodium levels. The plan is to observe the patient for changes in behavior and mental status, review medications, note any signs of hepatic encephalopathy, consult with family about usual behavior, reorient the patient as needed, provide consistent nursing care, and discuss the situation and expectations with the patient and family. The rationale is to properly assess, treat, and evaluate the patient given the fluctuating nature of their condition and risks of progression.

Uploaded by

Char Perea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Risk Factors: Risk for Acute Confusion After the shift family - Observe for changes in - Ongoing assessment of After the shift family members
- inability of liver to members or SO verbalize behavior and mentation: behavior and mental status or SO verbalized understanding
detoxify understanding of disease lethargy , confusion , is important because of the disease process and
- High ammonia level ( 186 process and prognosis and drowsiness, slowing or fluctuating nature of prognosis and the patient’s
umol/L ) the patient’s needs , slurring of speech , and hepatic encephalopathy or needs , recognized ad engaged
- Low sodium level recognize and engage in irritability.Arouse client at impending hepatic coma. in interventions to deal
( EASYLYTE ) ( 129.5 interventions to deal intervals as indicated. completely with the situation ,
mmol/L ) completely with the and provide for maximal
situation , and provide for - Review current medication - Adverse drug reactions or independence while meeting
maximal independence regimen. interactions may potentiate safety needs of the patient.
while meeting safety needs or exacerbate confusion.
of the patient.

- Note development or - Suggests elevating serum


presence of asterixis, fetor ammonia levels and
hepaticus , and seizure increased risk of
activity. progression to
encephalopathy.

- Consult with SO about - Provides baseline for


client’s usual behavior and comparison of current
mentation. status.

- Reorient to - Assists in maintaining


time,place,person,and reality orientation ,
situation,as needed. reducing cofusion and
anxiety.

- Provide continuity of care . - Familiarity provides


If possible , assign same reassurance , aids in
nurse over a period of time. reducing anxiety ad
provides a more accurte
documentation of subtle
changes.

- Discuss current situation - Client and SO may be


and future expectations. reassured that intellectual
as well as nemotional
function may improve as
liver involvement resolves.

You might also like