RISK FOR ACUTE CONFUSION
At risk for reversible disturbances of consciousness, attention, cogni-
tion, and perception that develop over time
• Alcohol use
• Male gender
• Decreased mobility or restraints
• 60 years
• Fluctuation in sleep–wake
• Metabolic abnormalities
• History of stroke
• Sensory deprivation
• Impaired cognition
• Substance abuse
• Urine retention
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
• Risk management
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
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.
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
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
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
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
SUGGESTED NIC INTERVENTIONS
Behavior Management: Overactivity/Inattention; Cognitive Stimula-
tion; Delirium Management; Hallucination Management; Reality
Cacchione, P. Z., et al. (2003, November). Risk for acute confusion in
sensory-impaired, rural, long-term care elders. Clinical Nursing Research,