急性混亂行為量表研擬的目的，在為臨床護理人員設計一份以行為觀察為主、隨時 隨地可使用並記錄的偵測急性混亂的工具。經由擷取行為項目、內容效度、初步測試、因素 分析、建構效度、信度分析、專家評審、項目選擇等步驟，得到一份20題的行為量表，其內 容一致性為0.8785。 問卷初步預試共包括七名個案、訪視79次，所表現出的行為以「對年、月、日沒有定向 感，經過提醒也弄不清」；「迷惘」；「對地點沒有定向感，經過提醒也弄不清」；「集中注意力 能力降低」；「自主動作改變」等頻次最多。個案表現出混亂行為的時間多數在日夜交替的時 段，個案間的表現亦不一致。 本研究的結果提供護理人員一份正確實用的偵測急性混亂工具，同時可使急性混亂的老 年人能被及時發現，得到適時的矯治，減少造成嚴重後遺症，甚至死亡的發生。

　　　　　The purpose of this study is to develop an instrument that nurses can use to detect acute confusion. After factor analysis and selection of items, a twenty item behavior rating scale was built. The internal consistency of this instrument was 8785. Seven confused hospitalized elderly patients with a combined 79 hospital visits were involved in the pilot study. Most of them exhibited disorganized thinking including, disassociation from time, and an inability to reorient to a new location. Other had a reduced attention span, altered motor function, and inability to follow directions. The hours at twilight and sunrise were accompanied by increased confusion. This study develops an easy to use, accurate instrument to detect confusion. It can quickly diagnose confusion to allow for timely treatment.