00128 Acute Confusion

Domain 5: perception/cognition
Class 4: cognition
Diagnostic Code: 00128
Nanda Tag: acute confusion
Diagnostic focus: confusion
Approved 1994 • Revised 2006, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « acute confusion ” is defined as: reversible alterations of consciousness, attention, knowledge and perception that develop in a short period of time, which is less than 3 months .

Definite characteristics

  • Alteration of psychomotor execution
  • Cognitive dysfunction
  • Difficulty in starting a behavior aimed at the objective
  • Difficulty in starting useful behavior
  • Hallucinations
  • Inappropriate monitoring of behavior aimed at the objective
  • Inappropriate monitoring of intentional behavior
  • erroneous perception
  • Neurocomportal manifestations
  • Psychomotor agitation

Related factors

  • Alteration of the sleep-vigilia cycle
  • Dehydration
  • deterioration of physical mobility
  • Inappropriate use of fasteners
  • Malnutrition
  • Pain
  • Deprivation/sensory deprivation
  • Inappropriate use of substances
  • Urinary retention

Risk population

  • People> 60 years of age
  • People with a history of stroke
  • Men

Associated problems

  • Decrease in the level of consciousness
  • Metabolism deterioration
  • Infections
  • Neurocognitive disorder
  • Pharmacological preparations

Suggestions of use

The term confusion can be used to describe different cognitive alterations. It may be difficult to determine whether the confusion is acute or chronic. Therefore, until detailed evaluations and analysis have been carried out, it may be necessary to use the most general term (not included in Nanda-I) of confusion. Acute confusion is presented suddenly and yields soon. Chronic confusion appears over time and is caused by progressive degenerative changes in the brain.

Suggested alternative diagnostics

  • Confusion (not included in Nanda-I)

NOC Results

  • Self -control of distorted thoughts: self -control of alterations in perception, the processes of thought and content of thought
  • Severity of substance abstinence: severity of the physical and psychological signs and symptoms caused by the abstinence of addictive drugs, toxic chemicals, tobacco or alcohol
  • Acute confusion level: severity of alteration in consciousness and cognition for a short period
  • Cognitive orientation: Ability to correctly identify person, time and place
  • Information processing: Ability to acquire, organize and use information

Evaluation objectives and criteria

  • Demonstrates cognitive orientation, revealed by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not affected)
    • He identifies himself
    • Identify the closest people
    • Identify the place where it is located
    • correctly identifies month, year, with the station
    • Identify important events of the present
  • Other examples

    The patient will be able to:

    • Have less and less confusion episodes
    • Modify your behavior and lifestyle to relieve or avoid new confusion episodes
    • Prove less restlessness and agitation
    • Do not react to hallucinations or delusions
    • Prove that you properly interpret the environment
    • Organize and process information logically
    • correctly identify habitual and family people
    • Read and understand written short phrases
    • Add and subtract precisely
    • Obey verbal instructions and orders
    • Keep motor responses to painful stimuli
    • Open your eyes to external stimuli
    • Be awake in the right periods
    • Have a normal electroencephalogram and electromyogram

    NIC Interventions

    • Memory training: facilitate memory
    • Cognitive stimulation: Promote alertness and understanding of the environment through the use of planned stimuli
    • Highway management: Promote security, comfort and reality orientation for a patient who suffers from hallucinations
    • Delirium management: Promote comfort, safety and reality orientation for a patient who presents false and fixed ideas who have little or no real basis
    • Acute confusional state management: provide a therapeutic and safe environment for a patient who is in an acute confusion state
    • Reality orientation: Promote the patient’s awareness of his personal identity and the environment
    • Treatment of substance consumption: alcohol abstinence: patient care that suddenly suspends alcohol consumption
    • Treatment of substance consumption: drug abstinence: patient care that is detoxifying drugs

    Nursing Activities

    • In general, nursing activities for this diagnosis focus on evaluating causal factors, providing security and stimuli to increase guidance, as well as communicate in simple terms and raise self -esteem.

    Valuations

    • Identify the possible causes of acute confusion syndrome (for example, pain, hypoglycemia, infection, medications)
    • Monitor the neurological state
    • Monitor the emotional state
    • Obtain the history of the previous mental state and any variation of it
    • Perform a complete mental exam
    • (NIC) Delirium management: Verify violent or self -harm contents in delusions

    Patient and family education

    • (NIC) Delirium management:
      • Educate the patient and the people around him, when delusions are caused by a disease (for example, acute confusion syndrome, schizophrenia or depression)
      • Instruct the patient and his closest people about medications

    Collaboration activities

    • (NIC) Delirium management: Administer antipsychotics and anxiolytic scheduled and extras, if necessary

    Others

    • Reassure the patient with frequent therapeutic communication
    • Touch the patient, if appropriate
    • Avoid mechanical subjection, if possible
    • Encourage the family and people closest to staying with the patient
    • Use nursing techniques (mouth care, posture, etc.) to facilitate well -being and sleep
    • Continue with the patient’s usual routines, to reduce anxiety
    • Offer options, but limit the alternatives if the patient seems frustrated or confused
    • Express instructions and explanations briefly and easily; Repeat as necessary
    • Make sure the patient has an identification bracelet
    • Orient the patient (for example, with respect to medical staff, the environment and care activities), as required
    • Promote the usual sleep-life rhythm (for example, open the curtain in the morning, keep the room dark or with a dim light at night)
    • Call the patient by name when starting any interaction
    • Respond to the bell in person instead of using the intercom
    • Explain routines and slowly and briefly, and with simple terms
    • Give the patient time to respond when alternatives or new information are offered
    • (NIC) Delirium management:
      • Focus comments on the underlying feelings and not on the contents of the delirium (“It seems that you are afraid”)
      • Avoid comments on false beliefs; Express doubts realistically
      • Encourage the patient to talk about delusions with their caregivers before acting on them
      • Help with self -care, if necessary
      • Maintain a safe atmosphere
      • Promote the patient’s safety and comfort and its environment when the patient is not able to control their behavior (for example, set limits, restrict the area, mechanical subjection or insulation)
      • Decrease excess environmental stimuli, if necessary
      • Maintain a consistent daily routine
      • Assign consistent caregivers daily

    At home

    • (NIC) Delirium management:
      • Monitor the patient’s ability to take care of himself
      • Teach the family and the closest people to treat a patient who suffers delirium
    • Assess the possible risks of security at home (unprotected stairs, etc.)

    Older people

    • Interventions are similar, despite the stage of development, although the incidence of confusion may be higher in older people
    • Keep in mind that older people can underestimate symptoms (for example, pain). Make sure that pain treatment is adequate