Assessment Objective: Confusion Lethargic Incoherent Agitated Oriented to person ONLY elevated serum lactate= 20.

3 mmol/L

Diagnosis Altered Mental Status related to metabolic imbalance

Planning Short Term Goal: After 1 hour of effective nursing intervention, the client will be calm and report an improved ability to cope with confused state Long Term Goal: After 8 hours of effective nursing intervention, the clients neurological status will be stable.

Intervention Independent Assess patients level of consciousness and changes in behavior

Rationale To provide baseline for comparison with ongoing assessment findings and to detect any improveme nt or decline inpatients neurologic function For the prevention of fall To prevent additional confusion To decrease confusion

Evaluation

GOAL MET

Side rails up

Limit noise and environmental stimulation Frequently mention time, place and date. Give short simple explanations each time you perform a procedure or task Speak slowly and clearly and allow time to respond

To reduce frustration

Schedule nursing care to include quiet times

Keep clients possessions in the same place

Plan clients routine

To help avoid sensory overload A consistent and stable environme nt reduces confusion and frustration To foster task completion and reduce confusion To promote a sense of continuity and create a sense of security and comfort.

Collaborative: Encourage family members to share stories and discuss familiar people and events with patient