Risk for delirium?

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We were talking in class the other day about "risk for delirium" and our teacher said it would make a great diagnosis. I happen to have a patient that fits the bill we discussed in class, but in both my diagnosis books, I can't find a risk for delirium dx...So what do I do if I can't find a resource?

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This is what she said that made me think she was confused:

Appeared confused aeb stated, “My friend is 5 years younger than me. She is 57 and I’m 68 so, let’s see, she is 11 years older than I am.” Also repeatedly asked who the night nurse that took care of her last time she was at Kindred and was confusing names.

I performed a head to toe with the teacher in the room and she agreed the patient seemed confused.

so your next response should have been. Mrs. XYZ...do you know what day it is today? Who is the president? Where are you right now?
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No, no longer a risk for confusion. I did ask her what day it was and if she knew where she was, which she did. I didn't think to ask her who the president was...I'll have to remember that one.

It was more noted in her conversation. Very forgetful, repeating questions we had already talked about, and specifically talking about her friend and messing the age up.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

but forgetfulness isn't really confusion is it?

Asking current events like the president is a good one. I have always felt the day of the week isn't fair as I have trouble remembering what day it is.

I once had the nicest lady who knew all the answers to all the question but was as confused as all get out. We kept documenting that the patient was confused an the ND one day threw a hissy fit and made this huge sarcastic comment in the progress notes and proceeded to chew out the new nurse caring for her about proper assessment and that nurses inadequate education.

I heard this and I was FURIOUS! I went up to him in the mist of his tirade and told him that his assessment skills needed refining and the patient was confused. When he looked at me ready to blow and asked what made me think she was confused and where I got my medical degree I told him that he should go ask the patient where she was....and NOT meaning the hospital. Ask her exactly WHERE she was meaning city state address.

He stormed off to the room....about 10 minuets later he emerged and crossed out his entire sarcastic progress note about nursing incompetence and wrote....This physician was wrong....PATIENT CONFUSED TO PLACE!!!! and apologized to the new grad.

The patient thought it was wonderful that her regular doctor came all the way to Canada to personally care for her and how nice the hospital bought her newspapers from the USA.

Assessment is always key.

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Ha! Oh wow! Well, she did know her city she stated the hospital she was at and the city. But what about her confusing the years and age? Would that be confusion? Or would she be put back to ris, for acute confusion b/c she is oriented to time to time, place, situation, person?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I would say she has more of Impaired memory......

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So looking at my book, Impaired memory r/t fluid and electrolyte imbalance, hypoxia aeb inability to recall information/events and low h&h and abnormal cmp....?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

But how does this fit YOUR patient? What evidence do YOU have that YOUR assessment revealed to you?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
So looking at my book, Impaired memory r/t fluid and electrolyte imbalance, hypoxia aeb inability to recall information/events and low h&h and abnormal cmp....?
Impaired memory:

Inability to remember or recall bits of information or behavioral skills; impaired memory may be attributed to pathophysiological or situational causes that are either temporary or permanent

Defining Characteristics

Experience of forgetting; forgets to perform a behavior at a scheduled time; inability to determine if a behavior was performed; inability to learn new information; inability to learn new skills; inability to perform a previously learned skill; inability to recall events; inability to recall factual information; inability to retain new information; inability to retain new skills

Related Factors (r/t)

Anemia; decreased cardiac output; excessive environmental disturbances; fluid and electrolyte imbalance; hypoxia; neurological disturbances

Now where in your assessment have you been able to identify hypoxia? You cannot use hypoxia if you don't have proof. Each patient must have at least one defining characteristic from the NANDA I definition.

So....your patient has impaired memory related to anemia, hospitalization, and fluid and electrolytye disturbance AEB....{low H/H (give labs), electrolyte imbalance (give lab) and extended illness/hospitalization (patient statement)} H/H of, Na of xyz and patient inability/confusion about friends/her age...patient statement.

Fluid and electrolyte may be a diagnosis of it's own and some instructors don't like these included in another diagnosis. However this one is a part of the definition so I believe it is acceptable....although I am not your instructor. :(

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It fits from

1. Appeared confused aeb stated, “My friend is 5 years younger than me. She is 57 and I’m 68 so, let’s see, she is 11 years older than I am.” Also repeatedly asked who the night nurse that took care of her last time she was at Kindred and was confusing names.

2. CBC 4/14/14: WBC low @ 3.7, RBC low @ 3.2, Hemoglobin low @ 9.4, Hematocrit low @ 28.1, PLT low @ 128

3. BUN high @ 53, Creatinine high @ 2, Albumin low @ 2.3, Bilirubin high @ 1.3, AST high at 41, GFR abnormal at 26.3

Can I say anemia? I wouldn't want to appear to be giving a medical dx, but she does have low RBC, low H&H, low platelets, which are signs of anemia...if I remember correctly...

Scratch hypoxia, my brain was going towards low hemoglobin effecting oxygen in the body. But she wasn't showing signs of hypoxia.

I would think electrolyte imbalance is a dx on it's own, it has its own defining characteristics, the main one I see as kidney disease. Am I wrong in thinking that?

I feel Impaired skin integrity, electrolyte imbalance and impaired memory would be good for her?

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Well, I feel acute confusion is good also...hmmmm...

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It fits from

1. Appeared confused aeb stated, “My friend is 5 years younger than me. She is 57 and I’m 68 so, let’s see, she is 11 years older than I am.” Also repeatedly asked who the night nurse that took care of her last time she was at Kindred and was confusing names.

2. CBC 4/14/14: WBC low @ 3.7, RBC low @ 3.2, Hemoglobin low @ 9.4, Hematocrit low @ 28.1, PLT low @ 128

3. BUN high @ 53, Creatinine high @ 2, Albumin low @ 2.3, Bilirubin high @ 1.3, AST high at 41, GFR abnormal at 26.3

Can I say anemia? I wouldn't want to appear to be giving a medical dx, but she does have low RBC, low H&H, low platelets, which are signs of anemia...if I remember correctly...

Scratch hypoxia, my brain was going towards low hemoglobin effecting oxygen in the body. But she wasn't showing signs of hypoxia.

I would think electrolyte imbalance is a dx on it's own, it has its own defining characteristics, the main one I see as kidney disease. Am I wrong in thinking that?

I feel Impaired skin integrity, electrolyte imbalance and impaired memory would be good for her?

Did I miss your impaired skin integrity assessment?

You can use anemia as a causative or risk factor for lots of things-- you will find them in the defining characteristics or related factors in NANDA-I 2012-2014.

If you have assessed her (including reading her chart and perhaps speaking to family or visitors) you should be able to figure out whether she has impaired memory or acute or chronic confusion (p 262 and 265 in your NANDA-I 2012-2014, which you had better have by now).

"Electrolyte imbalance" is not a nursing diagnosis, so you cannot make it. (And no, you cannot make it up, either.) So yes, you are wrong in making that nursing diagnosis.

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I have 2 posts running, kind of silly, I know. She has redness on her sacrum. I looked in her chart and there was no mention of confusion. There was no family for the one day I was with her, but I spoke with another student that had her a few weeks ago and she didn't notice confusion.

My book has risk for electrolyte imbalance?

Is it possible to have impaired memory and acute confusion together?

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