Confusion Nursing Diagnosis Care Plan: Your Expert Guide

Acute confusion, often termed delirium, marks a sudden shift in a person’s consciousness, attention span, cognitive abilities, and perception. It’s crucial to understand that this condition is usually reversible, acting as a key indicator of an underlying medical issue. The triggers for acute confusion can vary widely in severity, making it essential to pinpoint the exact cause for effective patient treatment and to alleviate the confusion itself.

As a healthcare professional, particularly a nurse, your primary role when faced with acute confusion is to ensure patient safety. Individuals experiencing symptoms like hallucinations, reduced consciousness, paranoia, or anxiety pose significant safety risks to themselves and those around them. Alongside administering medical treatment and continuously monitoring for any changes in their confused state, nurses are vital in applying therapeutic interventions to soothe the patient and foster a calm, healing environment.

Delving into the Root Causes of Acute Confusion

Identifying the ‘related to’ factors is crucial in addressing acute confusion effectively. Here are common causes:

• Advanced Age: Individuals over 60 years old are at an increased risk.
• Pre-existing Dementia: Conditions like dementia significantly heighten susceptibility.
• Hypoxemia: Insufficient oxygen levels in the blood.
• Substance Abuse: Alcohol or drug abuse plays a significant role.
• Medication Reactions: Adverse reactions to medications or anesthesia.
• Sleep Deprivation: Lack of adequate sleep.
• Elevated Fever: High body temperature.
• Seizures: Neurological disruptions.
• Trauma or Head Injury: Physical impacts affecting the brain.
• Hypoglycemia: Low blood sugar levels.
• Stroke or Transient Ischemic Attack (TIA): Cerebrovascular events.
• Post-Surgical Confusion: Confusion arising after surgery.

Recognizing the Signs and Symptoms: Subjective and Objective Data

Identifying both subjective and objective signs and symptoms is vital for a comprehensive nursing diagnosis and care plan for acute confusion.

Subjective Symptoms (Patient Reported)

• Hallucinations: Experiencing sensory perceptions that are not real.
• Paranoia: Feeling irrationally suspicious and distrustful of others.

Objective Signs (Nurse Assessed)

• Fluctuating Cognition/Consciousness: Changes in awareness and cognitive function.
• Agitation/Restlessness: Increased physical and emotional unease.
• Inappropriate Perceptions: Misinterpreting sensory information.
• Impaired Task Comprehension: Difficulty understanding or following instructions.
• Tremors: Involuntary shaking or trembling.

Setting Expected Outcomes: Goals for Care

Effective nursing care planning for acute confusion involves setting clear goals and expected outcomes:

• Treating the Underlying Cause: Aim to identify and treat the root cause of the confusion whenever possible.
• Restoring Orientation: The patient should regain orientation to person, place, time, and situation with an appropriate level of consciousness.
• Preventing Recurrence: Equip the patient to initiate lifestyle changes to prevent future episodes of acute confusion or delirium.
• Understanding Contributing Factors: The patient will be able to verbalize factors that contribute to fluctuations in their cognitive state.

Comprehensive Nursing Assessment for Acute Confusion

A thorough nursing assessment is the foundation of effective care. Here are key assessment areas for acute confusion:

1. Identify Contributing Factors/Conditions:

• Acute confusion is a symptom, and determining its origin is paramount. Explore recent surgeries, infections, traumas, medication reactions, or exposure to toxins.

2. Evaluate Substance Use and Withdrawal:

• Consider alcohol or drug abuse, as these can depress the central nervous system, leading to confusion. Withdrawal can also induce delirium and related symptoms.

3. Closely Monitor Vital Signs:

• Physiological imbalances can have serious consequences. Hypoxia, for example, can lead to confusion due to oxygen deprivation in the brain. Monitor for tachycardia and low oxygen saturation levels.

4. Review Recent Medication Use:

• Certain medications like benzodiazepines, anticonvulsants, and narcotics can cause toxicity and CNS depression. Lab work can confirm levels of some medications.

5. Determine Baseline Cognition:

• If possible, consult family or previous records to establish the patient’s normal cognitive baseline. This helps in differentiating new-onset confusion and identifying causative factors.

6. Assess Psychiatric History:

• Consider if the patient has a psychiatric history, as they might be experiencing an exacerbation of a mental illness. Be aware of “sundowning” in Alzheimer’s patients, where confusion worsens later in the day.

7. Monitor Lab Values:

• Lab results can reveal infections (blood cultures, CBC), UTIs (urinalysis, particularly in older adults), liver disease (ammonia levels), and glucose or sodium imbalances, all of which can contribute to confusion.

Essential Nursing Interventions for Managing Acute Confusion

Effective nursing interventions are critical for patient recovery and managing acute confusion:

1. Orient Patient Frequently:

• Regular reorientation to staff, surroundings, and procedures can reduce agitation and fear. Avoid arguing with illogical thoughts, as this can worsen delirium.

2. Implement Safety Measures:

• Patient safety is paramount. Use bed alarms, keep the bed low, and ensure the call bell is within reach to prevent falls. 1:1 monitoring may be needed for high-risk patients.

3. Manage Drug or Alcohol Withdrawal:

• Treat withdrawal with benzodiazepines based on CIWA-Ar scores, addressing symptoms like nausea, tremors, anxiety, and hallucinations.

4. Treat Underlying Conditions:

• Address infections with antibiotics, discontinue causative medications, and correct electrolyte and glucose imbalances.

5. Minimize Stimuli:

• Reduce overstimulation by keeping the environment quiet, limiting noise, and providing undisturbed rest. Family visits should be assessed for their calming effect.

6. Prevent Sundowning:

• Establish a daily routine, ensure light exposure, limit daytime naps, and provide familiar items to help manage sundowning.

7. Reduce Polypharmacy:

• Simplify medication regimens in consultation with healthcare providers to reduce medication-related confusion.

8. Ensure Support at Discharge:

• Coordinate with case management for home safety needs, including home health services, family support, and substance abuse treatment programs.

9. Educate for Prevention:

• Teach patients and families about causes and symptoms to prevent recurrence. For example, educate older adults at risk for UTIs about preventative measures.

Nursing Care Plans: Examples for Acute Confusion

Nursing care plans are essential tools for structuring care and prioritizing interventions. Here are examples focusing on different causes of acute confusion:

Care Plan #1: Acute Confusion Related to Sepsis

Diagnostic Statement: Acute confusion related to sepsis secondary to pneumonia, as evidenced by increased agitation and hallucinations.

Expected Outcomes:

• Patient will maintain or improve level of consciousness.
• Patient will experience fewer episodes of delirium.
• Patient will remain safe and free from injury.

Assessments:

1. Assess mental status: To monitor cognitive decline.
2. Perform CAM assessment: For quick and accurate delirium screening.
3. Monitor lab results: To assess sepsis progression and systemic perfusion.

Interventions:

1. Administer antibiotics: To treat the underlying pneumonia and sepsis.
2. Administer fluids and electrolytes: To optimize perfusion.
3. Create a calm environment: To minimize sensory overload.
4. Anticipate antipsychotics: For managing delirium symptoms cautiously.
5. Refer to psychiatry: If psychotic behaviors worsen.
6. Provide reality orientation: To improve cognitive function.

Care Plan #2: Acute Confusion Related to Head Trauma

Diagnostic Statement: Acute confusion related to head trauma as evidenced by fluctuation in cognition and consciousness.

Expected Outcomes:

• Patient will achieve a Glasgow Coma Scale score of 13 or higher.
• Patient will be oriented to person, place, and time.

Assessments:

1. Assess imaging findings: To understand the extent of head trauma.
2. Monitor for increased ICP: Watch for signs like headaches, blurred vision, and behavior changes.
3. Monitor neuro vital signs: To detect early deterioration in cognitive function.

Interventions:

1. Elevate head of bed: To improve cerebral venous drainage.
2. Anticipate intubation: For deteriorating consciousness.
3. Ensure temperature control: To prevent increased cerebral metabolic demand.
4. Provide orientation aids: Clocks, calendars, and familiar objects.
5. Provide cognitive stimulation: To promote mental recovery.

Care Plan #3: Acute Confusion Related to Opioid Withdrawal

Diagnostic Statement: Acute confusion related to opioid withdrawal as evidenced by reduced ability to follow commands and increased agitation.

Expected Outcomes:

• Patient will regain and maintain orientation and consciousness.
• Patient will engage in behaviors to prevent future withdrawal.

Assessments:

1. Determine substance use history: To identify potential withdrawal.
2. Assess mental status: Look for anxiety, disorientation, and hallucinations.
3. Check for opioid withdrawal signs: Such as lacrimation, muscle pain, and GI distress.

Interventions:

1. Maintain a safe, calm environment: To prevent overstimulation.
2. Encourage use of sensory aids: To improve environmental interpretation.
3. Give simple directions: Allowing ample response time.
4. Educate family for home monitoring: For early detection of changes.
5. Discuss medication review: To prevent misuse and adverse reactions.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
2. Alcohol and Drug Withdrawal. (n.d.). Permanente Medicine. https://mydoctor.kaiserpermanente.org/mas/structured-content/Health_Topic_Alcohol_and_Drug_Withdrawal_-_Addiction_Med.xml
3. Bhutta, B. S., Alghoula, F., & Berim, I. (2021, August 7). Hypoxia. NCBI. Retrieved December 2, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK482316/
4. Bokhari, A.M. (2023). Bacterial sepsis. Medscape. https://emedicine.medscape.com/article/234587-overview
5. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
6. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
7. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
8. Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
9. Graff-Radford, J. (2019, April 23). Sundowning: Late-day confusion. Mayo Clinic. Retrieved December 2, 2021, from https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511
10. Sellers, E. M. (n.d.). CIWA-Ar for Alcohol Withdrawal. MDCalc. Retrieved December 2, 2021, from https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal#use-cases
11. Shaikh, F.& Waseem, M. (2022). Head trauma. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430854/