Nursing Care Plan for Acute Confusional State

Nursing care plan for acute confusional state 1

Confusion is a mental state characterized by a change in thinking and attention deficit, followed by problems in comprehension. Confusion in accompanied by memory loss and sometimes short-tempered alternative to sleepy.


  • Common causes are alcohol and drugs.
  • Confusion can also follow fever, heart failure, head injury and anesthesia.
  • Another cause is hypoxia, hypoglycemia, weight liquid electrolyte disturbances, sepsis, liver and renal failure, poison and drug overdoses.
  • Chronic dementia can cause confusion that beafect weighs in memory, judgment, thinking abstractly, which cause loss of independent social and personal
  • Alzheimer’s disease.

There are three mechanisms of the development of acute confusion;

  1. Damage to the brain swelling, loss of oxygen, blood, or both (functional impairment).
  2. Damage to the nervous system by the action of chemicals or other substances.
  3. Rebound depression centers of the brain activity. The injury resulting in an increase in ICP.

Chemicals that cross the blood-brain barrier, such as alcohol damage neuron cell metabolism. When the action of the drug in patients below the center overactive brain. This overactivity develop acute confusion, combativesness, and abnormal behavior.

Chronic confusional state resulting from the destruction of brain tissue, biochemical imbalances, or compression of the brain. Just as an example; Alzheimer’s disease deficiency of acetylcholine, a neurotransmitter that is needed on the short memory. Other disorders can be caused by viruses eg; cretzfeld-jacob disease, encephalitis.

Clinical manifestations

  • Attention disorders, loss of concentration.
  • Restlessness.
  • Emotionally labile.
  • Insomnia / drowsiness.
  • Vivid nightmare.
  • Looks like anxiety and be crazy (going crazy).
  • Disruption continues to stupor and coma.
  • Fluctuations in cognitive (thinking skills and reasoned).
  • Lost memory.
  • Delirium.
  • Perceptual errors, hallucinations, illusions and delusions.

Diagnostic assessment
Nothing specific, however;

  • CT or MRI to determine the structural causes such as tumors.
  • Laboratory to determine the cause of metabolic.
  • Complete blood count, electrolytes, vitamin B 12, folate, liver and thyroid function.
  • Toxic drug screening test.
  • Electroencephalogram.
  • Lumbar puncture for CSF analysis.

Nursing Care Plan for Acute Confusional State

Nursing Diagnosis : Sleep pattern disturbance daytime naps and nighttime hallucinations

Goal: to increase patient’s sleep patterns

characterized by; sleep 4-6 hours every night and do not sleep in the daytime hours.


  1. At night planned not to interrupt sleep.
  2. Assess the pattern of REM sleep with eye movements, if the REM phase should not be disturbed (recall cycle requires 2-3 hours of sleep and loss of REM can increase confusion)
  3. Patients should be active every so tired during the day at night, so it can rest
  4. Giving medication to sleep, the sleep cycle is given as change.


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