Nursing Diagnosis and Nursing Intervention

Nursing Diagnosis Interventions : Acute Confusion

Nursing Diagnosis: Acute Confusion
Kimberly Hickey and Gail B. Ladwig

NANDA Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle

Defining Characteristics: Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior; fluctuation in psychomotor activity; misperceptions; fluctuation in cognition; increased agitation or restlessness; fluctuation in level of consciousness; fluctuation in sleep-wake cycle; hallucinations

Related Factors: 60 years of age; dementia; alcohol abuse; abuse; delirium; uncontrolled pain; multiple morbidities and medications
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Distorted Thought Control
·         Information Processing
·         Memory
·         Neurological Status: Consciousness
·         Safety Behavior: Personal
·         Sleep
Client Outcomes
·         Cognitive status restored to baseline
·         Obtains adequate amount of sleep
·         Demonstrates appropriate motor behavior
·         Maintains functional capacity
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Delusion Management
Nursing Interventions and Rationales
·         Assess client’s behavior and cognition systematically and continually throughout the day and night as appropriate. Rapid onset and fluctuating course are hallmarks of delirium (Murphy, 2000). The Confusion Assessment Method is sensitive, specific, reliable, and easy to use (Inouye et al, 1990). Nurses play a vital role in assessing acute confusion because they provide 24- hours-a-day care and see the client in a variety of circumstances (Marr, 1992). Delirium always involves acute change in mental status; therefore knowledge of the client’s baseline mental status is key in assessing delirium (Flacker, Marcantonio, 1998).
·         Perform an accurate mental status exam that includes the following:
o    Overall appearance, manner, and attitude
o    Behavior observations and level of psychomotor behavior
o    Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by client)
o    Insight and judgment
o    Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)
o    Attention
Abnormal attention is an important diagnostic feature of delirium (Flacker, Marcantonio, 1998). Delirium is a state of mind, while agitation is a behavioral manifestation. Some clients may be delirious without agitation and may actually have withdrawn behavior. This is a hypoactive form of delirium. Some clients have a mixed hypoactive/hyperactive type of delirium (O’Keefe, Lavan, 1999).
·         Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). Such alterations may be contributing to confusion and must be corrected (Matthiesen et al, 1994). Medications are considered the most common cause of delirium in the ICU (Harvey, 1996).
·         Treat underlying causes of delirium in collaboration with the health care team: Establish/maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucose levels, blood pressure.
·         Communicate client status, cognition, and behavioral manifestations to all necessary providers. Monitor for any trending of these. Recognize that client’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as client preference for caregivers (Inouye et al, 1990). Careful monitoring may allow for various symptoms to be related to various causes and interventions (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
·         Lab results should be closely monitored and physiological support provided as appropriate. Once acute confusion has been identified, it is vital to recognize and treat the associated underlying causes (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
·         Establish or maintain elimination patterns. Disruption of elimination may be a cause for confusion (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997). Changes in elimination patterns may also be a symptom of acute confusion. Prompt response to requests for assistance with elimination in addition to timed voids may assist in maintaining regular elimination, orientation, and patient safety (Rosen, 1994).
·         Plan care that allows for appropriate sleep-wake cycle. Disruptions in usual sleep and activity patterns should be minimized as those clients with nocturnal exacerbations endure more complications from delirium.
·         Review medication. Medication is one of the most important modifiable factors that can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives (Flacker, Marcantonio, 1998).
·         Decrease caffeine intake. Decreasing caffeine intake helps to reduce agitation and restlessness (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
·         Modulate sensory exposure and establish a calm environment. Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion (Rosen, 1994). Clients with a hyperactive form of delirium often have increased irritability and startle responses and may be acutely sensitive to light and sound (Casey et al, 1996).
·         Manipulate the environment to make it as familiar to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight. An environment that is familiar provides orienting clues, maintains an appropriate balance of sensory stimulation, and secures safety (Rosen, 1994).
·         Identify self by name at each contact; call patient by his or her preferred name. Appropriate communication techniques for clients at risk for confusion (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
·         Use orientation techniques. However, if client becomes distressed or argumentative about what is real, do not argue with the client. Rather, explore the emotion behind the client’s non–reality-based statements (Rosen, 1994).
·         Offer reassurance to the client and use therapeutic communication at frequent intervals. Client reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety (Harvey, 1996).
·         Provide supportive nursing care. Delirious patients are unable to care for themselves as a result of their confusion. Their care and safety needs must be anticipated by the nurse (Foreman, 1999).
·         Identify, evaluate, and treat pain quickly (see care plan for Acute Pain). Untreated pain is a potential cause for delirium.
·         Mobilize client as soon as possible; provide active and passive range of motion. Older clients who had a low level of physical activity before injury are at a particular risk for acute confusion (Matthiesen et al, 1994).
·         Provide sufficient medication to relieve pain. Older clients may give inaccurate pain histories; underreport symptoms; not want to bother the nurse; and exhibit restlessness, agitation, or increased confusion (Matthiesen et al, 1994).
·         Because anxiety and sensory impairment decrease the older client's ability to integrate new information, explain hospital routines and procedures slowly and in simple terms, repeating information as necessary (Matthiesen et al, 1994).
·         Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes). Continuity of care helps decrease the disorienting effects of hospitalization (Matthiesen et al, 1994).
·         If clients know that they are not thinking clearly, acknowledge the concern. Confusion is very frightening (Matthiesen et al, 1994).
·         Do not use the intercom to answer a call light. The intercom may be frightening to an older confused client (Matthiesen et al, 1994).  
·         Keep client's sleep-wake cycle as normal as possible (e.g., avoid letting client take daytime naps, avoid waking clients at night, give sedatives but not diuretics at bedtime, provide pain relief and backrubs). Acute confusion is accompanied by disruption of the sleep-wake cycle (Matthiesen et al, 1994).
·         Maintain normal sleep/wake patterns (treat with bright light for 2 hours in the early evening). This facilitates normal sleep/wake patterns (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
Home Care Interventions
·         Monitor for acute changes in cognition and behavior. An acute change in cognition and behavior is the classic presentation of delirium. It should be considered a medical emergency.
Client/Family Teaching
·         Teach family to recognize signs of early confusion and seek medical help. Early intervention prevents long-term complications (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

Nursing Diagnosis Interventions Chronic Confusion

Nursing Diagnosis: Chronic Confusion
Kimberly Hickey, Betty J. Ackley, and Nancy English

NANDA Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by a decreased ability to interpret environmental stimuli and a decreased capacity for intellectual thought processes, which manifest as disturbances of memory, orientation, and behavior

Defining Characteristics: Altered interpretation/response to stimuli; clinical evidence of organic impairment; altered personality; impaired memory (short and long term); impaired socialization; no change in level of consciousness

Related Factors: Multi-infarct dementia; Korsakoff's psychosis; head injury; Alzheimer's disease; cerebrovascular accident
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Cognitive Orientation
·         Information Processing
·         Memory
·         Neurological Status: Consciousness
Client Outcomes
·         Remains content and free from harm
·         Functions at maximal cognitive level
·         Participates in activities of daily living at the maximum of functional ability
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Dementia Management
·         Environmental Management
·         Reality Orientation
·         Surveillance: Safety
Nursing Interventions and Rationales
·         Determine client's cognitive level using a screening tool such as the Mini Mental State Exam (MMSE). Using a standard evaluation tool such as the MMSE can help determine the client's abilities and assist with planning appropriate nursing interventions (Agostinelli et al, 1994; Espino et al, 1998).
·         Gather information about client pre-dementia functioning, including social situation, physical condition, and psychological functioning. Knowing the client's background can help the nurse identify agenda behavior and use validation therapy, which will provide guidance for reminiscence. Background information may help the nurse to understand client’s behavior if client becomes delusional and hallucinates.
·         Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. As much as 50% of clients with dementia have depressive symptoms (Cleeland, 1997).
·         Ensure that client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids. Clients with dementia lose the ability to make good judgments and can easily harm self or others.
·         Place an identification bracelet on client. Clients with dementia wander and can become lost; identification bracelets increase client safety.
·         Avoid exposing client to unfamiliar situations and people as much as possible. Maintain continuity of caregivers. Maintain routines of care through established mealtimes, bathing, and sleeping schedules. Send familiar person with client when client goes for diagnostic testing or into unfamiliar environments. Situational anxiety associated with environmental, interpersonal, or structural change can escalate into agitated behavior (Gerdner, Buckwalter, 1994).
·         Keep environment quiet and nonstimulating; avoid using buzzers and alarms if possible. Minimize sights and sounds that have a high potential for misinterpretation such as buzzers, alarms, and overhead paging systems. Sensory overload can result in agitated behavior in a client with dementia. Misinterpretation of the environment can also contribute to agitation.
·         Begin each interaction with client by identifying self and calling client by name. Approach client with a caring, loving, and accepting attitude and speak calmly and slowly. Dementia clients can sense feelings of compassion. A calm, slow manner projects a feeling of comfort to the client (Stolley, 1994).
·         Touch client gently, stroking hand or arm in a soothing fashion if acceptable in client's culture.
·         Give one simple direction at a time and repeat as necessary. Use verbal and physical prompts, and model the desired action if needed and possible. People with dementia need time to assimilate and interpret your directions. If you rephrase your question, you give them something new to process, increasing their confusion (Stolley, 1994).
·         Break down self-care tasks into simple steps (e.g., instead of saying, "Take a shower," say to client, "Please follow me. Sit down on the bed. Take off your shoes. Now take off your socks."). Dementia clients are unable to follow complex commands; breaking down an activity into simple steps makes completing the activity more feasible (Agostinelli et al, 1994).
·         Keep questions simple; yes or no questions are often preferable to open-ended questions. Use positive statements and actions and avoid negative communication. Negative feedback leads to increased confusion and agitation. It is more effective to go along with the client and then redirect as necessary.
·         If eating in the dining room causes increased agitation, let client leave and eat in a quieter environment with a smaller number of people. The noise and confusion in a large dining room can be overwhelming for a dementia client and can result in agitated behavior. It is preferable to have dementia clients eat in small groups (Sloane, 1998).
·         Provide finger food if patient has difficulty using eating utensils or if unable to sit to eat. Feeding oneself is a complex task and may prove challenging for someone with significant dementia (Finley, 1997).
·         Provide boundaries by placing red or yellow tape on the floor or by using a stop sign. Boundaries help the client identify safe areas; older clients can more easily see red and yellow than other colors.
·         Assess the etiology of wandering before or rather than attempting to control the wandering. Wandering indicates a problem and need for intervention; therefore the reason for the wandering behavior needs to be determined (Algase, 1999).
·         Write client's name in large block letters in the room and on client's clothing and possessions. Use symbols rather than words to identify areas such as the bathroom or kitchen.
·         Limit visitors to two and provide them with guidelines on appropriate topics to discuss and how to best communicate with client. (See Client/Family Teaching for how to converse with a memory-impaired person.)
·         Set up scheduled quiet periods in a recliner or room. Use blankets and other environmental cues to define rest periods. Quiet times allow the client's anxiety and building tension levels to decrease (Hall et al, 1995). Fatigue has been associated with the onset of increased confusion and agitation (Stolley, 1994).
·         Provide quiet activities, such as listening to classical or religious music, or other cues that promote relaxation in the afternoon or early evening. An increase in confusion and agitation, referred to as sundowning syndrome, may occur in the late afternoon and early evening. Quiet activities can provide a calming environment.
·         Provide simple activities for the client, such as folding washcloths and sorting or stacking activities. Avoid misleading and frightening stimuli, which may include television, mirrors, and pictures of people or animals. Repetitive activities give the client with dementia a positive outlet for behavior (Burgener et al, 1998). Dementia clients see, hear, and perceive a different world than other people. They may not recognize themselves in the mirror and be afraid of the stranger they see so close to them.
·         Consider using doll therapy. Ask family members to bring a large, safe doll or stuffed animal such as a teddy bear. Doll therapy can be soothing to some dementia clients (Bailey, 1992; Paulanka, Griffin, 1993).
·         If client becomes increasingly confused and agitated, perform the following steps:
    • Monitor client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. An acute change in behavior is a medical emergency and should be evaluated. Many physiological factors can result in increased agitation of clients with dementia (Gerdner, Buckwalter, 1994; Alexopoulos et al, 1998).
    • Monitor for psychological causes, including changes in environment, caregiver, and routine; demands to perform beyond capacity; and multiple competing stimuli (including discomfort). It is important for the nurse to recognize precipitating events and subsequent behavior to prevent furthers incidents of agitation (Bair et al, 1999).
    • Avoid confrontations with the client; allow client to dissipate energy by performing repetitive tasks or by pacing.
·         If client is delusional or hallucinating, do not confront him or her with reality. Use validation therapy to verbally reflect back the emotions that the client appears to be experiencing. Use statements such as, "It must be frightening to see a fire at the end of your bed," "I can see that you are afraid," "I will stay with you," or "Can you tell me more about what is going on right now?" Orienting the client to reality can increase agitation; validation therapy conveys empathy and understanding and can help determine the internal stimulus that is creating the change in behavior (Feil, 1993). In one study, training in validation therapy for staff resulted in decreased doses of psychotherapeutic medications and incidences of behavior problems (Fine, Rouse-Bane, 1995).
·         Decrease stimuli in the environment (e.g., turn off television, take client to a quiet place). Institute activities associated with pleasant emotions, such as playing soft music the client likes, looking through a photo album, providing favorite food, or using simulated presence therapy. Decreasing stimuli can decrease agitation. Reassuring activities, such as simulated presence therapy wherein client listens to a tape of a loved one's phone conversation, can help bring about pleasant emotions that soothe the client (Woods, Ashley, 1995).
·         Avoid using restraints if at all possible. Restraints are not benign interventions and should be used sparingly and judiciously only when alternatives to manage the behaviors have been tried and been unsuccessful. Side effects include falls, increased confusion, deconditioning, and incontinence (Tinetti, Liu, Ginter, 1992).
·         Use prn or low dose regular dosing of psychotropic or antianxiety drugs only as a last resort. They are effective in managing symptoms of psychosis and aggressive behavior. Start with the lowest possible dose. Psychotropic drugs such as haloperidol (Haldol) and resperidone (Risperdol) may decrease client function and have side effects that need to be monitored (Katz et al, 1999).
·         Avoid use of anticholinergic medications such as Benadryl. Anticholinergic medications have a high side effect profile that includes disorientation, urinary retention, and excessive drowsiness (Nurses Drug Alert, 1995). The anticholinergic side effects outweigh the antihistaminic effects.
·         For predictable difficult times, such as during bathing and grooming, try the following:
    • Massage the client's hands lovingly or use therapeutic touch to relax the client. Hand massage and therapeutic touch have been shown to induce relaxation that may allow care activities to take place without difficulty (Snyder, Egan, Burns, 1995).
    • Use positive behavioral reinforcement for each of the small steps involved in bathing, such as praising client for walking toward the shower, sitting in the shower chair, and removing items of clothing. Positive behavioral reinforcement for desired behavior is effective for clients with dementia (Boehm et al, 1995). Consider a towel bath if shower or tub bathing is too stressful for client (Hall, Buckwalter, 1999).
    • Treat the client with the utmost respect and give individualized care. Treating confused clients with respect and individualizing care can decrease aggression and increase nursing staff satisfaction (Maxfield, Lewis, Cannon, 1996).
·         For early dementia clients with primarily symptoms of memory loss, see care plan for Impaired Memory. For clients with self-care deficits, see appropriate care plan (Feeding Self-care deficit, Dressing/grooming Self-care deficit, Toileting Self-care deficit).
·         NOTE: Most of the preceding interventions apply to the geriatric client.
·         Use reminiscence and life review therapeutic interventions; ask questions about client's work, child rearing, or time spent in the service. Ask questions such as "What was really important to you as you look back?" Reminiscence and life review can help an older person reframe and accept life events (Burnside, Haight, 1994).
·         Assess for the influence of cultural beliefs, norms, and values on the family or caregiver understanding of chronic confusion or dementia. What the family considers normal and abnormal health behavior may be based on cultural perceptions (Leininger, 1996).
·         Inform client family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia. An understanding of dementia behavior will enable the client family/caregiver to provide the client with a safe environment.
·         Refer family to social services or other supportive services to assist with meeting the demands of caregiving for the client with dementia. Black caregivers of dementia clients may evidence less desire than others to institutionalize their family members and are more likely to report unmet service needs (Hinrichsen, Ramirez, 1992). Families of dementia clients may report restricted social activity (Haley, 1995).
·         Encourage family to make use of support groups or other service programs. Studies indicate that some minority families of clients with dementia may use few support programs even though these programs could have a positive impact on caregiver well-being (Cox, 1999).
·         Validate the family members’ feelings with regard to the impact of client behavior on family lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
Home Care Interventions
·         NOTE: Keeping the client as independent as possible is important. However, because community-based care is usually less structured than institutional care, in the home setting, the goal of maintaining safety for the client takes on primary importance.
·         Provide support to family of client with chronic and disabling condition.
·         If client will require extensive supervision on an ongoing basis, evaluate client for day care programs. Refer family to medical social services to assist with this process if necessary. Day care programs provide safe, structured care for the client and respite for the family. Respite care for caregivers is an essential part of successful long-term care for a confused client.
·         Encourage family to include client in family activities when possible. Reinforce use of therapeutic communication guidelines (see Client/Family Teaching) and sensitivity to the number of people present. These steps help the client maintain dignity and lead to familiar socialization of the client.
·         Assess family caregivers for caregiver burden. Caring for a loved one with a dementing process is highly stressful. Respite care is a necessary component to the overall care plan.
Client/Family Teaching
·         Recommend that the family develop a memory aid wallet or booklet for client that contains pictures and text that chronicle the client's life. Using memory aids such as wallets or booklets helps dementia clients make more factual statements and stay on topic, and it decreases the number of confused, erroneous, and repetitive statements (Bourgeois, 1992).
·         Teach family how to converse with a memory-impaired person. Guidelines include the following:
    • Ask client to have a conversation with you.
    • Guide conversation to specific, nonthreatening topics and redirect the conversation back on topic when client begins to ramble.
    • Reassure and help out when the client gets stuck or cannot find the right words.
    • Smile and act interested in what client is saying even if unsure what it means.
    • Thank client for talking.
    • Avoid quizzing client or asking a lot of specific questions.
    • Avoid correcting or contradicting something that was stated even if it is wrong.
These guidelines can help family interact more effectively with client and decrease frustration levels (Bouregois, 1992).
·         Teach family how to set up environment and use care techniques/interventions listed so that client will experience a progressively lowered stress threshold. Alzheimer's clients are unable to deal with stress; decreasing stress can decrease confusion and changes in behavior (Hall, 1991; Stolley, 1994).
·         Discuss with the family what to expect as the dementia progresses.
·         Counsel the family about resources available with regard to end-of-life decisions and legal concerns.
·         Inform family that as dementia progresses, hospice care may be available in the terminal stages in the home to help the caregiver. Hospice services in the late stages of dementia can help support the family with nursing services and visitation by primary care provider, home health aides, social services, volunteer visitors, and a spiritual counselor if desired as the client is dying (Boyd, Vernon, 1998).
NOTE: The nursing diagnoses Impaired Environmental interpretation syndrome and Chronic Confusion are very similar in definition and interventions. Impaired Environmental interpretation syndrome must be interpreted as a syndrome where other nursing diagnoses would also apply. Chronic Confusion may be interpreted as the human response to a situation or situations that require a level of cognition no longer available to the individual. Further research is underway to make this distinction clear to the practicing nurse.
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