Complete Nursing Assessment of patients with Delirium


Delirium, or acute confusional state is sudden severe confusion and rapid changes in brain function that occur with physical or mental illness. Delirium represents an organically caused decline from a previously-attained level of cognitive functioning. Delirium typically appears suddenly with a readily-identifiable time of onset, such as a time space of a few hours, or overnight.

Complete Nursing Assessment of patients with Delirium

1. Identity

The identity of the patient includes name, age, gender, ethnicity / cultural background, civil status, education, occupation and address.

2. The main complaint

The main complaint or the main reasons that caused the client comes to treatment (according to the client and or family). The main symptoms are decreased consciousness.

3. Predisposing Factors

Finding a mental disorder that is the basis of making a diagnosis as well as determine the level of interference as well as describing the structure of personality that might explain the history and development of the existing mental disorders. Of psychiatric symptoms, the etiology of the disease is not known bodily, but necessary internal and neurological examinations were thorough. The symptoms are more determined by premorbid mental state, psychological defense mechanisms, psychosocial circumstances, the nature of help from family, friends and health care workers, social structure and the characteristics of the surrounding culture. Mental disorders are psychotic or nonpsychotic disorders caused by brain tissue function. Impaired function of brain tissue can be caused by physical illness which is mainly about the brain (meningoencephalitis, cerebrovascular disorders, brain tumur etc.) or are primarily outside the brain or skull (typhoid, endometriosis, heart failure, toxemia of pregnancy, intoxication, etc.) .

4. Physical Examination

Decreased awareness and thereafter there is amnesia. Decreased blood pressure, tachycardia, febrile, weight loss due to decreased appetite and would not eat.

5. Psychosocial

a. Genogram
The results of the study found, monozygotic twins influence higher than dizygotic twins.

b. Self-concept

Self-image, stressors that cause changes in self-image because the pathological processes of disease.
Identity, varies according to the level of individual development.
Roles, role transition from healthy to be sick, discrepancy between the roles with other roles.
Ideal self, a desire that does not correspond to reality and existing capabilities.
Self-esteem, inability to achieve the goals that the client feels low self-esteem because of his failure.

c. Social relations

Various factors in the community that makes a person removed or loneliness, which can not be overcome, causing severe consequences such as delusions and hallucinations. Self-concept is formed by a pattern of social relations particularly with people who are important in the lives of individuals. If the relationship is not healthy, then individuals in internal emptiness. The development of social relations is not adequate cause failure of the individual to learn to maintain communication with others, as a result clients tend to separate themselves from others and is only involved in their own mind that does not require the control of others. This situation lead to loneliness, social isolation, shallow relationships and dependent.

d. Spiritual

Religion and belief is still strong but no or less capable in performing worship in accordance with their religion or belief.

6. Mental status

a. Clients look untidy and are unable to care for himself.

b. Talks loud, fast and incoherent.

c. Motor activity, motor changes can manifest an increase in motor activity, restlessness, impulsive, automatic.

d. Natural feeling
Clients look of fear and despair.

e. Affective and emotional.
Affective changes occur because the client is trying to make some sense of distance, as if directly experiencing these feelings can cause anxiety. This situation raises the changes affect a client is to protect themselves, because the affect that has changed, enabling clients to deny the painful emotional impact of the external environment. Client's emotional response may seem inappropriate because it comes from the frame of mind has changed. Affective changes are blunt, flat, inappropriate, excessive and ambivalent.

f. Interaction during the interview
Client's attitude toward the examiner less cooperative, less eye contact.

g. Perception
Perception involves thinking and emotional understanding of an object. Changes in perception may occur at one or more of the five senses, namely sight, hearing, touch, smell and taste. Changes in perception can be mild, moderate and severe or prolonged. Change in perception is the most common hallucination.

h. The process of thinking

Assessment reality privately by the client is subjective assessments associated with people, objects or events that are not logical. (Autistic thinking). The client does not re-examine the truth of reality. Thought autistic basis, changes in thought processes that can be manifested by the notion of primitive, loss of association, magical thinking, delusions, linguistic change (exhibit impaired abstract thinking that it seems the client regression and a narrow mindset.

i. level of consciousness
Decreased consciousness, confused. Disorientation to time, place and person.

j. Memory
Impaired memory that just happened (the events of a few hours or days ago), and that has long ago occurred (incident a few years ago).

k. The level of concentration
Clients are not able to concentrate

l. Capability assessment
Mild impairment in judgment or decision.

7. The daily needs of clients
a. Sleep: Client sleeplessness due to anxiety, restlessness, lying down or sitting and restless. Sometimes it is difficult to wake up in the night and go back to sleep. The sleep may be disturbed during the night, so do not feel refreshed in the morning.
b. Appetite: The client does not have the appetite or eating just a little, out of desperation, feeling unworthy, limited activity so that weight loss can occur.
c. Elimination: The client may be impaired urinate, sometimes more often than usual, because of sleeplessness and stress. Sometimes constipation can occur, due to disturbed eating patterns.

8. Coping mechanisms

If clients are not successful, failed, then he would neutralize, deny or destroy by developing various patterns of coping mechanisms. Inability to constructively address the primary causes of the formation of a pattern of pathological behavior. Coping mechanisms used by someone in a state of Delerium is to reduce eye contact, using the words fast and hard (grumble).

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