Acute Confusion Nursing Diagnosis and Care Plans

Acute Confusion Nursing Care Plans Diagnosis and Interventions

Acute Confusion NCLEX Review and Nursing Care Plans

Acute confusion or delirium can be defined as a clinical syndrome wherein there are associated abnormalities in the person’s thought perception and awareness levels that hinder normal and daily activities.

It is intermittent and acute in onset, oftentimes with both hypoactive and hyperactive features. It is very common in the elderly, many of which fail to return to their former functions.

Causes of Acute Confusion

Causes of Acute confusion come from a variety of factors and they include:

  1. Acute infections – examples that are linked to acute confusion are urinary tract infection, pneumonia, sepsis, viral infections, meningitis, encephalitis, cerebral abscess, and malaria.
  2. Prescribed medications – typical associated drug classes are benzodiazepines, certain analgesics, anticholinergics, anticonvulsants, anti-Parkinsonism medications, and steroids.
  3. Surgical – The patient being postoperative is one of the causes of acute confusion.
  4. Toxic substances – Instances are substance abuse or withdrawal, alcohol intoxication or withdrawal, carbon monoxide poisoning, exposure to heavy metals, and barbiturate withdrawal.
  5. Vascular disorders – Instances are cerebrovascular accidents both hemorrhagic or infarction in origin, cardiac failure, subdural hemorrhage, subarachnoid hemorrhage, vasculitis, cerebral venous thrombosis, and migraines.
  6. Metabolic issues – Examples are hypoxia, electrolyte abnormalities (such as hyponatremia), blood sugar discrepancies (such as hypoglycemia or hyperglycemia), issues of the liver and the kidneys.
  7. Vitamin deficiencies – Instances wherein there is either thiamine, nicotinic acid or vitamin B12 insufficiencies may cause acute confusion.
  8. Endocrine problems – Conditions such as hypothyroidism, hyperthyroidism, hypopituitarism, hypoparathyroidism, hyperparathyroidism, Cushing’s disease, porphyria, and carcinoid may cause acute confusion.
  9. Trauma, particularly head injuries
  10. Epilepsy episodes, especially postictal
  11. Neoplasia – Certain instances such as primary cerebral malignancy, metastasis to the brain, and paraneoplastic syndromes.
  12. Other causes – Other causes such as urinary retention, fecal impaction, and multiple etiologies, even those without any known causes may precipitate acute confusion.

Risk Factors to Acute Confusion

The risk factors that may predispose a patient to acute confusion are the following:

  • Age – 65 years and above
  • Being male
  • Having a pre-existing condition, usually cognitive related such as stroke, etc.
  • The severity of dementia
  • Sever comorbidity
  • Previous instances of delirium
  • Operative dynamics – It has been suggested that certain types of operations, such as a hip fracture or emergency operations, increase the risk.
  • Certain conditions such as burns, AIDS, infection, dehydration, low serum albumin
  • Existing hip fracture or severe ailment
  • Drug abuse and dependence such as benzodiazepines – It has been attributed to almost half of acute confusion cases.
  • Substance abuse, specifically alcohol
  • Extremes of sensory issues such as hypothermia or hyperthermia
  • Visual or hearing problems
  • Poor mobility
  • Social isolation
  • Undue stress
  • Being terminally ill
  • Transfer to a new environment
  • Being admitted in the ICU
  • Abnormalities in creatinine or urea levels

A triggering factor is typically needed, together with some risk factors, for acute confusion to occur. The presence of multiple risk factors further compounds the risk, consequently eliciting acute confusion with the smallest of precipitants.

 Signs and symptoms of Acute Confusion

The clinical manifestations of acute confusion include the following:

  • Usually presents acute or subacutely
  • Fluctuating course
  • Clouded, disoriented and impaired consciousness
  • Poor concentration
  • Memory deficits, usually short term memory loss
  • Sleep-wake cycle abnormalities that include day-sleeping
  • Perception abnormalities such as hallucinations
  • Agitation
  • Emotional lability – This is referred to as rapid and exaggerated mood changes associated with strong feelings.
  • Psychotic ideas, usually presented on short bouts with simple content
  • Neurological signs such as tremors, unsteady gait.

Diagnosis of Acute Confusion

Diagnosing acute confusion should be guided by the clinical manifestation and is aimed at looking for the underlying causes. The work-up includes the following:

  • Full medical history, which will include mental state examinations
  • Full physical examination which will look for manifestations of infections such as rashes, lymphadenopathy, constipation, etc.
  • Blood works such as Complete blood count, urea, electrolytes, creatinine, liver function tests, cardiac enzymes, vitamin B12 levels, syphilis serology, autoantibody screen and prostate-specific antigen will be tested to assess for acute confusion etiologies.
  • Urine dipstick testing and microscopy for glucose levels
  • Blood cultures
  • Electrocardiogram
  • Pulse oximetry and arterial blood gas
  • Chest x-ray, if possible abdominal x-ray
  • Advanced imaging such as Brain CT-scan
  • Lumbar puncture
  • Electroencephalogram as additional confirmatory work-up

Treatment for Acute Confusion

Treatment management for acute confusion can be divided into four:

  1. Supportive management. Supportive management goals include assisting the patient to orientation to reality and activities of daily living and they include;

  • Using clear communication schemes
  • Setting reminders for the day, time, location, and identification of persons surrounding the patient
  • Availability of clocks
  • Ensuring familiar objects at home are brought with the patient especially sensory aids such as eyeglasses, walking aids, or hearing aids.
  • Maintaining staff consistency who attends to the patient – both doctors and nurses.
  •  Relaxation activities such as watching television.
  • Active participation of the healthcare providers and significant others to care management

2. Environmental measures – Environmental measures that will help in decreasing acute confusion include:

  • Avoiding sensory extremes (e.g., overstimulation)
  • Ensuring adequate space and sleep. Allow the patient to follow a normal sleep-wake cycle.
  • Single room for the patient as possible.
  • Avoid the use of unfamiliar words to the patient such as medical jargon
  • Control excessive noise.
  • Adjust room lighting; Utilize low bulb wattages at night.
  • Adjust room temperature to comfortable levels (between 21-23°C)
  • Employ interpreters if possible and as needed
  • Allow patient to do activities of daily living such as walking.
  • Ensure optimal nutrition for the patient by having him eat nutritious foods that he recognizes.

3. Medical management.  Medical management focuses on correcting the underlying conditions through the following;

  • Managing infection – Infection is a common cause of delirium, specifically urinary tract infection.
  • Addressing constipation – Patients with acute confusion has poor eating and bowel habits that predispose them to develop constipation. Anticipate the use of laxatives for the patient.
  • Urinary retention – Urinary may contribute to the patient’s agitated state while having acute confusion. Managing this will help diminish agitation episodes.
  • Dehydration and electrolyte abnormalities – Acutely confused patients are usually dehydrated and may need supplemental hydration and electrolytes depending on severity. Those with severe episodes would necessitate further management and parenteral supplementation.
  • Pain control – Consistent paracetamol usage is part of a multi-factorial approach for acute confusion in managing the patient’s pain that could otherwise increase agitation if not controlled. As needed dosages of weak opioids may be used but only under strict monitoring.
  • Medication – Investigate if certain medications were started or stopped recently for they may have effects on the patient’s condition. Certain drug regimens may either lessen or worsen a patient’s acute confusion. Anti-psychotics may have beneficial effects on aggressive patients. For acute confusion due to alcohol withdrawal, benzodiazepines are the drug of choice in controlling agitation.

4. Management post-discharge. Management considerations after the patient is discharged include:

  • Take note that symptoms may last longer versus the underlying condition.
  • This suggests that patients will be discharged with tenacious issues.
  • The chronic issues highlighted consist of disorientation, depression, and inattentiveness.
  • Support and assistance should also be given to the significant others or home caregivers of the patient.

Acute Confusion Nursing Diagnosis

Acute Confusion Nursing Care Plans 1

Nursing Diagnosis: Disturbed Thought Processes related to delusional thinking secondary to acute confusion as evidenced by inaccurate interpretation of both internal and external stimuli

Desired Outcome: The patient will be able to maintain orientation to reality and recognize discrepancies in thought and behavior.

Acute Confusion Nursing InterventionsRationale
Assess the patient’s attention span and level of distractibility in making decisions or problem-solving.This gives the healthcare provider baseline data on how the patient will participate, interact and fulfill the planned therapeutic regimen.
Perform intermittent neurological and behavioral assessments as needed. Compare findings with the baseline data.This gives the healthcare provider ample data in recognizing significant changes and therefore prompting for timely modifications in the therapeutic management.
Assist with treatment regimen prescribed to address underlying conditions such as anorexia, sleep disorders, biochemical imbalances, etc.Improving the patient’s cognitive condition will also improve the treatment for correcting latent medical or psychiatric issues.
Ensure that safety measures are enacted such as the use of side rails, padding, and close supervision of a competent watcher for the patient.Safety is paramount for a patient with acute confusion and disturbed thought processes. This prevents injury for both the patient and others.
Work together, with the patient, for possible solutions regarding specific conflicts that remain unsolved.Unresolved issues may hinder the progress of the therapeutic regimen for the patient. Facing this head-on in finding solutions will help in developing coping behaviors for the patient’s condition.
Identify and support the patient’s accomplishments, including responsibilities fulfilled, projects accomplished, etc.Recognizing and giving positive feedback to a patient’s undertakings can help with the anxiety and lessen reliance on delusions as sources of self-worth.
Educate the patient in interventional techniques for episodes of irrational or negative thoughts.Thought stopping by utilizing the command “Stop” or by interrupting with loud sounds, such as clapping, will hinder irrational thoughts. This distraction technique assists the patient in making better thinking, and consequently to better behaviors.

Acute Confusion Nursing Care Plans 2

Nursing Diagnosis: Impaired verbal communication related to cognitive impairment secondary to acute confusion as evidenced by inaccurate interpretation of both internal and external stimuli.

Desired Outcome: The patient will be able to effectively use communication tools and techniques and respond appropriately to both internal and external stimuli.

Acute Confusion Nursing InterventionsRationale
Evaluate the patient’s history for neurological problems that could affect speaking such as tumor, multiple sclerosis, sensory problems, etc.Evaluation of history is needed to look for contributing factors to the patient’s difficulties.
Assess for the following conditions: Preferred language for both oral and written communication       Preferred means of communication (oral, written, gestures)     Capacity to understand spoken words     Capacity to comprehend written words, pictures, and gestures    Language preferences play a tremendous role in learning. Ensuring which one the patient is comfortable in using would indicate either the success or failure of care management.   Patients may have varied skills in communications yet will gravitate towards one preference.   It should be noted that sentence construction in verbal language differs from gestured forms.   The use of interpreters would benefit both the patient and caregiver so as to clarify if the instructions were understood.
Study the patient’s non-verbal cues, including their needs.Ample time should be allotted by the healthcare provider in order to address the patient’s needs, especially in the presence of communication deficits.
Consider the use of alternative communication tools in the absence of capable interpreters.Alternatives such as cue cards, electronic messaging, and the likes are useful tools for interpreting the patient’s needs and ideas to his caregivers.
Ensure eye contact is maintained with the patient as he communicates. Stand closer and within the patient’s line of sight.Patients may have additional sensory defects that may hinder communication. Positioning nearer the patient allows them to see the healthcare provider’s face or lips so as to convey understanding of relayed information.

Acute Confusion Nursing Care Plans 3

Nursing Diagnosis: Risk for Injury related to suicidal ideations, illusions, and hallucinations secondary to acute confusion

Desired Outcome: The patient will be able to remain free of injuries.

Acute Confusion Nursing InterventionsRationale
Assess for the patient’s impairment, particularly sensory-perception issues.Altered senses (sight, taste, hearing, smell, and touch) can affect the environmental perception of a person. This altered perception predisposes the patient to inaccurate responses to stimuli, thereby increasing their risks.
Observe for signs of physical injury such as bruises, burns, fractures, lacerations, fearfulness, withdrawal episodes, etc.These may indicate possible and deliberate abuse, either by the patient or others, and would necessitate immediate medical attention.
Educate the patient on navigating his surroundings, including how to call for assistance.Familiarity with the layout of living spaces safeguards the patient from accidents. Teaching them how to seek assistance doubles their safety from hazards.
For patients with confusion, acute or chronic, orientating to reality should be paramount in rendering care.Reality orientation assists the patient in decreasing confusion that can otherwise aggravate injury risks while having agitation.
Ensure for a capable watcher, either a significant other or another caregiver, to be with the patient at all times.This prevents accidental falling of the patient suffering from acute confusion. Furthermore, this ensures patient safety due to impaired thought processes.
Assign a room near the nurses’ station for a patient with acute confusion.This allows the healthcare provider to closely monitor the patient, especially those with higher risks of harm. It also ensures timely interventions for harmful actions the patient may take.
Confirm the patient’s concerns regarding risks.Validation of the perceived risks of the patient ascertains that these concerns are heard and that the healthcare provider takes time and understanding the situation. This promotes a healthier nurse-patient relationship.

Acute Confusion Nursing Care Plans 4

Nursing Diagnosis: Impaired Memory related to cognitive impairment secondary to acute confusion as evidenced by the inability to follow commands, either or both simple and complex.

Desired Outcome: The patient will be able to function at his optimal level by employing modifications to compensate for deficits.

Acute Confusion Nursing InterventionsRationale
Examine the patient’s cognitive functions, including memory.Assessment tools such as the General Practitioner Assessment of Cognition (GPCOG) are helpful in recognizing the patient’s baseline mental functions. Findings stemming from these tools are useful for further evaluation and therapeutic management.
Orient the patient to his environment as needed. Utilize radios, calendars, televisions in assisting the patient for reorientation.Reality orientation assists the patient in recognizing himself and environment, thereby reducing confusion episodes.
Propose the use of calendars or journals for reminders.Written cues support the patient’s memory in recalling actions or decisions.
Employ the use of alternative therapies such as guided meditation, massage, exercises.These activities may lower the patient’s stress levels, and consequently improve the patient’s overall mood. Unnecessary stress may complicate further existing memory loss.
Help the patient in preparing his medication box.Using medication boxes ensures that the patient will be able to take his prescribed medications on time. It also promotes independence and improves the patient’s self-worth.
Evaluate the patient for episodes of sensory deprivation, poor nutrition, dehydration, infection, etc.Recognizing other underlying symptoms that can cause confusion and sudden shifts in mental capacities ensures timely intervention and prevention of complications.

Acute Confusion Nursing Care Plans 5

Nursing Diagnosis: Risk for Other-directed Violence related to suspiciousness of others secondary to acute confusion

Desired Outcome: The patient will be able to prevent hurting others and use age-appropriate behaviors when interacting with others.

Acute Confusion Nursing InterventionsRationale
Assess for the patient’s baseline mood and affect, including perception and response to stimuli.Recognizing deviations from the patient’s baseline ensures timely, appropriate, and effective interventions. Furthermore, this helps the nurse in formulating care management that is both effective and appropriate for the patient.
Communicate with the patient clearly the set boundaries and limits to acceptable behaviors.  Setting limits ensures a level of safety to both the patient and the healthcare provider. Furthermore, it guarantees mutual respect that is necessary for every intervention to be effective.
Help the patient in formulating effective coping skills.This promotes acceptance for the patient as valuable persons despite episodes of unacceptable behavior. Utilizing coping skills increases the patient’s self-esteem.
Allow the patient for social interaction with orders, under guidance by the healthcare provider.A healthy social interaction is necessary even for patients with tendencies for violence. This enables the client to employ acceptable behavior. Giving positive feedback for acceptable decorum or behavior lets the patients know that they meet expectations.
Promote client and family interaction.Family interactions can help the patient to improve decorum and the family in addressing unacceptable behavior that the patient may have during care management under the guidance of a healthcare giver.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Nursing Stat Facts
Nursing Stat Facts

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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