Nursing diagnosis – RISK FOR ACUTE CONFUSION

RISK  FOR  ACUTE  CONFUSION

DEFINITION

At risk for reversible disturbances of consciousness, attention, cogni-

tion, and perception that develop over time

RISK FACTORS

• Alcohol use

• Male gender

• Decreased mobility or restraints

• Medication/drugs

• Dementia

•   60 years

• Fluctuation in sleep–wake

• Pain

cycle

• Metabolic abnormalities

• History of stroke

• Sensory deprivation

• Impaired cognition

• Substance abuse

• Infection

• Urine retention

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Respiratory function

• Neurocognition

• Risk management

• Nutrition

• Sleep/rest

EXPECTED OUTCOMES

The patient will

• Remain free from injury.

• Have a stable neurologic status.

• Obtain adequate amounts of sleep.

• Maintain optimal hydration and nutrition.

• Begin to participate in ADLs.

• Report feeling increasingly calm.

Family members will

• Report an improved ability to cope with the patient’s confused state.

• State the causes of acute confusion.

• Express the necessity for informing healthcare providers about

acute confusion.

SUGGESTED NOC OUTCOMES

Cognitive Orientation; Information Processing; Memory

INTERVENTION 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

improvement or decline in the patient’s neurologic function.

Perform: Use appropriate safety measures to protect patient from

injury. Avoid physical restraints to prevent agitating patient.

Address patient by name and tell him or her your name, mention

time, place, and date frequently throughout day, and have a large

clock and a calendar close by and refer to those aids to foster

awareness of self and environment.

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Give patient short, simple explanations each time you perform a

procedure or task to decrease confusion. Speak slowly and clearly

and allow patient ample time to respond to reduce his or her frus-

tration and promote task completion.

Schedule nursing care to provide quiet times for patient to help

avoid sensory overload. Follow consistent patient routine to aid task

completion and reduces confusion.

Keep patient’s possessions in the same place. A consistent, stable

environment reduces confusion and frustration and aids completion

of ADLs. Ask family to bring labeled family photos and other

favorite articles to create a more secure environment for patient.

Encourage patient to perform ADLs, dividing tasks into small,

critical units. 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.

Inform: Discuss episodes of acute confusion with patient and family

members to make sure they understand the cause of confusion.

Review measures family members can take at home to help

patient if he or she begins to exhibit signs of confusion and to

report future episodes. Tell them to give patient short explanations

of activities; remind him of time, place, and date frequently; speak

slowly and clearly and allow patient ample time to respond; and

provide patient with a consistent routine. Teaching empowers

patient and family to take greater responsibility for his or her

healthcare needs.

Attend: Have a staff member stay at patient’s bedside, if necessary, to

protect patient from harm. Enlist family member to help calm patient.

Encourage family to share stories and discuss familiar people and

events with patient to promote a sense of continuity, security, and

comfort.

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

Behavior Management: Overactivity/Inattention; Cognitive Stimula-

tion; Delirium Management; Hallucination Management; Reality

Orientation

Reference

Cacchione, P. Z., et al. (2003, November). Risk for acute confusion in

sensory-impaired, rural, long-term care elders. Clinical Nursing Research,
12(4), 340–355.

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