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.

Nursing diagnosis – CHRONIC CONFUSION

CHRONIC  CONFUSION

DEFINITION

Irreversible, long-standing, and/or progressive deterioration of intel-

lect and personality characterized by decreased ability to interpret

environmental stimuli; decreased capacity for intellectual thought

processes; and manifested by disturbances of memory, orientation,

and behavior

DEFINING CHARACTERISTICS

• Altered interpretation, response to stimuli, and/or personality

• No change in LOC

• Clinical evidence of organic impairment

• Short- and long-term memory loss

• Progressive or long-standing impaired cognition or socialization

RELATED FACTORS

• Alzheimer’s disease

• Korsakoff’s psychosis

• Cerebral vascular accident

• Multi-infarct dementia

• Head injury

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Neurocognition

• Role/relationships

• Self-care

EXPECTED OUTCOMES

The patient will

• Remain free of injury caused by confusion.

• Exhibit no signs of depression.

• Maintain weight.

• Have an environment structured for maximum functioning.

• Participate in selected activities to fullest extent possible.

• Receive adequate emotional support.

Family members will

• Discuss strategies to provide care and help patient cope.

• Maintain safety of patient’s home environment.

• Receive information on the options available for long-term care.

• Assist patient to prepare for relocation to long-term care facility.

SUGGESTED NOC OUTCOMES

Client Satisfaction: Safety; Cognition; Cognitive Orientation

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s cognitive abilities and changes in behav-

ior to provide baseline data.

Weigh patient and include instructions for regular weighing as

part of care plan to monitor patient’s nutritional status.

Perform: Take steps to provide a stable physical environment and

consistent daily routine for patient. Stability and consistency enhance

functioning.

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Inform: Teach family members or caregiver strategies to help patient

cope with his condition: Place an identification bracelet on patient to

promote safety; touch patient to convey acceptance; avoid unfamiliar

situations when possible to help ensure consistent environment; provide

structured rest periods to prevent fatigue and reduce stress; refrain from

asking questions patient can’t answer to avoid frustration; provide

finger foods if patient won’t sit and eat to ensure adequate nutrition;

select activities based on patient’s interests and abilities and praise him

or her for participating in activities to enhance his or her sense of self-

worth; use television and radio carefully to avoid sensory overload;

limit choices patient has to make to provide structure and avoid confu-

sion; label familiar photos to provide a sense of security; use symbols,

rather than written signs, to identify patient’s room, bathroom, and

other facilities to help patient identify surroundings; place patient’s

name in large block letters on clothing and other belongings to help

him recognize his belongings and prevent them from becoming lost.

Attend: Encourage family members to watch mental status

assessments to provide a more accurate view of patient’s abilities.

Evaluate patient’s ability to perform self-care activities, including

ability to function alone and drive a car. Safety is a primary concern.

Ask family members about their ability to provide care for patient

to assess the need for assistance.

Project an attentive, nonjudgmental attitude when listening to

them to help ensure that you receive accurate information.

Manage: Assist family members in contacting appropriate community

services. If necessary, act as an advocate for patients within health-

care system to help secure services needed for ongoing care.

Provide family members with information concerning long-term

healthcare facilities. If patient is to be moved to a long-term care

facility, explain the decision to him in as simple and gentle terms as

possible to facilitate comprehension.

Allow patient to express feelings regarding the move to facilitate

grieving over loss of independence. Provide psychological support to

patient and family members to alleviate stress they may experience

during relocation.

Communicate all aspects of discharge plan to staff members at

patient’s new residence. Documenting a discharge plan and commu-

nicating it to caregivers help ensure continuity of care. Interventions

should ensure patient’s dignity and rights.

SUGGESTED NIC INTERVENTIONS

Cognitive Stimulation; Dementia Management; Family Involvement

Promotion; Reality Orientation

Reference

Rader, J., et al. (2006, April). The bathing of older adults with dementia.

American Journal of Nursing, 106(4), 40–48.

Nursing diagnosis – ACUTE CONFUSION

ACUTE  CONFUSION

DEFINITION

Abrupt onset of reversible disturbances of consciousness, attention,

cognition, and perception that develop over a short period of time.

DEFINING CHARACTERISTICS

• Fluctuations in LOC, psychomotor activity, cognition, and

sleep–wake cycle

• Hallucinations

• Impaired perceptive ability

• Increased agitation or restlessness

• Misperceptions

• Lack of motivation to initiate and follow through with goal-

directed behavior

RELATED FACTORS

• Alcohol abuse

• Drug abuse

• Delirium

• Fluctuations in sleep–wake cycle

• Dementia

• Over 60 years of age

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Respiratory function

• Neurocognition

• Risk management

• Nutrition

• Sleep/rest

EXPECTED OUTCOMES

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

confused state.

• 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-

tional confusion.

Use appropriate safety measures to protect patient from injury.

Avoid physical restraints to prevent agitating patient.

67
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-

cal 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.

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

Management; Orientation

Reference

Buettner, L., & Fitzsimmons, S. (2006, July). Mixed behaviors in dementia: The

need for a paradigm shift. Journal of Gerontological Nursing, 32(7), 15–22.