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Acute Confusion

Acute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.
Confusion is a term nurses use often to represent a pattern of cognitive impairments. It is a behavior that indicates a disruption in cerebral metabolism. Acute confusion (delirium) can befall in any age group, which can evolve over a period of hours to days. Factors that increase the risk for delirium and confusional states can be categorized into those that increase baseline vulnerability including underlying brain disease such as dementia, stroke, or Parkinson’s disease and those that precipitate the disturbance like infection, sedatives, and immobility. The change is commonly caused by a medical condition, substance intoxication, or medication side effect.
A person with dementia can experience acute confusion (delirium). Careful assessment is indicated to determine prehospital function and deliberate with family to perceive deterioration.
Related Factors
Here are some factors that may be related to Acute Confusion:
  • Over 60 years of age
  • Dementia
  • Alcohol abuse, drug abuse
  • Delirium [including febrile epilepticum (following or instead of an epileptic attack), toxic and traumatic]
Defining Characteristics
Acute Confusion is characterized by the following signs and symptoms:
  • Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior
  • Fluctuation in psychomotor activity (tremors, body movement)
  • Misperceptions
  • Fluctuation in cognition
  • Increased agitation or restlessness
  • Fluctuation in level of consciousness
  • Fluctuation in sleep-wake cycle
  • Hallucinations (visual/auditory)
Goals and Outcomes
The following are the common goals and expected outcomes for Acute Confusion:
  • Patient has diminished episodes of delirium.
  • Patient regains normal reality orientation and level of consciousness.
  • Patient verbalizes understanding of causative factors when known.
  • Patient initiates lifestyle/behavior changes to prevent or minimize recurrence of the problem.
  • Patient demonstrates appropriate motor behavior.
  • Patient participates in activities of daily living (ADLs).
Nursing Assessment
Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly patient), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors.
Rationale ⇒Baseline information assists in developing a specific plan.
Conduct an accurate mental status exam that includes the following:
  • Overall appearance, manner, and attitude
  • Behavior observations and level of psychomotor behavior
  • Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by patient)
  • Insight and judgment
  • 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)
  • Attention
  • Assess patient’s behavior and cognition systematically and continually throughout the day and night as appropriate.
  • Rationale ⇒ Delirium always involves acute change in mental status; therefore knowledge of the patient’s baseline mental status is key in assessing delirium.
  • Evaluate and report possible physiological changes (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects).
  • Rationale ⇒ Such changes may be contributing to confusion and must be corrected.
  • Closely monitor lab results. Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate).
  • Rationale ⇒ Once acute confusion has been recognized, it is necessary to identify and treat the associated underlying causes.
  • Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
  • Rationale ⇒ This should be done to determine degree of impairment.
  • Note occurrence/timing of agitation, hallucinations, violent behaviors. Assess for sundown syndrome.
  • Rationale ⇒ This phenomenon associated with confusion occurs in the late afternoon. The patient exhibits increasing restlessness, agitation, and confusion. Sundowning may be a sign of sleep disorders, hunger, thirst, or unmet toileting needs.
Nursing Interventions
  • Aid with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, pain management).
  • Rationale ⇒ Assisiting with treatment of underlying problem is important to maximize level of function and prevent further deterioration.
  • Orient patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
  • Rationale ⇒ Increased orientation ensures greater degree of safety for the patient.
  • Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli.
  • Rationale ⇒ Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient.
  • Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings).
  • Rationale ⇒ The confused patient may not completely understand what is happening. Presence of family and significant others may enhance the patient’s level of comfort.
  • Give simple directions. Allow sufficient time for patient to respond, to communicate, to make decisions.
  • Rationale ⇒ This communication method can reduce anxiety experienced in strange environment.
  • Give simple directions. Allow sufficient time for patient to respond, to communicate, to make decisions.
  • Rationale ⇒ This communication method can reduce anxiety experienced in strange environment.
  • 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.
  • Rationale ⇒ To treat underlying causes of delirium in collaboration with the health care team.
  • Communicate patient’s status, cognition, and behavioral manifestations to all necessary providers.
  • Rationale ⇒ Recognize that patient’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as patient preference for caregivers.
  • Tell patient to decrease caffeine intake.
  • Rationale ⇒ Decreasing caffeine intake helps to reduce agitation and restlessness.
  • Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes).
  • Rationale ⇒ Continuity of care helps decrease the disorienting effects of hospitalization.
  • Assist the family and significant others in developing coping strategies.
  • Rationale ⇒ The family needs to let the patient do all that he or she is able to do to maximize the patient’s level of functioning and quality of life.
  • Teach family to recognize signs of early confusion and seek medical help.
  • Rationale ⇒ Early intervention prevents long-term complications.
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