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학습 자료 둘러보기 →Any acute onset (over hours to days) of confusion, agitation, or hallucinations in an older adult is delirium until proven otherwise. It is a medical emergency reflecting a physiological insult to the brain.
The first and most critical nursing action is a comprehensive physical examination. Focus on vital signs, O2 saturation, lung sounds, and signs of infection (e.g., UTI, pneumonia) or focal neurological deficits to identify the underlying medical trigger.
Do not assume a psychiatric cause. Delirium is rarely idiopathic in geriatric patients; a thorough physical assessment to rule out physiological causes like hypoxia or sepsis takes absolute priority over a detailed psychosocial or medication history.
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