Abrupt onset of reversible disturbances of consciousness, attention,
cognition, and perception that develop over a short period of time.
• Fluctuations in LOC, psychomotor activity, cognition, and
• Impaired perceptive ability
• Increased agitation or restlessness
• Lack of motivation to initiate and follow through with goal-
• Alcohol abuse
• Drug abuse
• Fluctuations in sleep–wake cycle
• Over 60 years of age
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
• Risk management
The patient/family will
• Experience no injury.
• Maintain a stable neurologic status.
• Start to participate in ADLs.
• Report feeling increasingly calm and improved ability to cope with
• Express an understanding of the importance of informing other
healthcare providers about episodes of acute confusion.
SUGGESTED NOC OUTCOMES
Cognition; Cognitive Orientation; Information Processing
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s LOC and changes in behavior to provide
baseline for comparison with ongoing assessment ﬁndings. Monitor
neurologic status on a regular basis to detect any improvement or
decline in patient’s neurologic function.
Perform: Limit noise and environmental stimulation to prevent addi-
Use appropriate safety measures to protect patient from injury.
Avoid physical restraints to prevent agitating patient.
Address patient by name and tell him your name to foster aware-
ness of self and environment. Also, frequently mention time, place,
and date; have a clock and a calendar in sight and refer to these aids.
Give patient short, simple explanations each time you perform a
procedure or task to decrease confusion. Speak slowly and clearly
and allow time to respond to reduce frustration.
Schedule nursing care to include quiet times to help avoid sensory
overload. Plan patient’s routine and be consistent to foster task com-
pletion and reduce confusion.
Ask family members to bring labeled family photos and articles to
create a more secure environment for patient. Keep patient’s posses-
sions in the same place. A consistent, stable environment reduces
confusion and frustration and aids completion of ADLs.
Inform: Review home measures to use and report if patient begins to
exhibit signs of confusion. Tell caregiver to provide short explanations
of activities and orient the patient frequently; speak slowly and clearly
and allow patient time to respond; and provide patient with a consis-
tent routine. Teaching empowers patient and family members to take
greater responsibility for the healthcare needs.
Attend: Have a staff member stay at patient’s bedside, if necessary,
to protect him or her from harm.
Enlist the aid of family member to help calm patient. Patiently
encourage patient to perform ADLs, dividing tasks into small, criti-
Be patient and speciﬁc in providing instructions. Allow time for
patient to perform each task. These measures enhance his or her self-
esteem as well as help prevent complications related to inactivity.
Encourage family members to share stories and discuss familiar
people and events with patient to promote a sense of continuity and
create a sense of security and comfort. Support family members’
attempts to interact with patient to provide positive reinforcement.
Allow time before and after visits for family members to express feel-
ings. Listening to family members in an open and nonjudgmental
manner promotes coping and may help you assess and monitor
patient’s condition. Reassure patient and family that confusion is tem-
porary to help relieve anxiety. Always include patient in discussions.
Manage: Confer with physician about diagnostic test results, patient’s
progress in behavior, and patient’s LOC. A collaborative approach to
treatment helps ensure high-quality care and continuity of care.
SUGGESTED NIC INTERVENTIONS
Cognitive Stimulation; Delirium Management; Hallucination
Buettner, L., & Fitzsimmons, S. (2006, July). Mixed behaviors in dementia: The
need for a paradigm shift. Journal of Gerontological Nursing, 32(7), 15–22.