00173 Risk Of Acute Confusion

Domain 5: perception/cognition
Class 4: cognition
Diagnostic Code: 00173
Nanda label: acute confusion risk
Diagnostic focus: confusion
Approved 2006 • Revised 2013, 2017 • Evidence level 2.2

NANDA Nursing Diagnosis Definition

Nanda’s nursing diagnosis «” is defined as: susceptible to the appearance of reversible alterations of consciousness, attention, cognition and perception that develop in a short period of time , which can compromise health.

Risk 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 of confusion risk, not included in NANDA-I. 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

Other examples

The patient will be able to:

  • Identify the changes you can make in your lifestyle to reduce the effect of modifiable risk factors
  • Recognize and inform about signs and symptoms of acute confusion
  • Also see the objectives for acute confusion

NIC Interventions

  • Medicines management: Promotion of a safe and effective use of prescribed and recipe medications
  • Sleep improvement: facilitation of regular sleep-vigilia cycles
  • Reality orientation: Promote the patient’s awareness of his personal identity, time and environment
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions

Nursing Activities

In general, nursing activities for this diagnosis focus on identifying risk factors and performing specific preventive actions for these risk factors, such as medication management, patient orientation to reality and improve of sleep.

Valuations

  • Evaluate the presence of symptoms of acute confusion, such as agitation, restlessness, fluctuations of cognitive functions, level of consciousness, psychomotor activity or the sleep-vigilia cycle; hallucinations, errors in the perception, disorientation or lack of motivation to initiate or maintain behaviors aimed at an objective
  • Monitor the neurological state
  • Monitor the emotional state
  • Monitor the acid-base balance of liquids and electrolytes
  • Obtain the history of the mental state and any experience experienced

Patient and family education

  • Point out the presence of lifestyle factors that increase the risk of acute confusion; Explain the relationship

Collaboration activities

  • Take into account possible pharmacological interactions in patients who take many medications; comment with the main providers of health services

Others

  • Avoid mechanical subjection, if possible
  • Promote the usual sleep-vigilia cycle (such as opening the curtain in the morning, keeping the room in the 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
  • Reduce excessive environmental stimuli, if necessary
  • Increase environmental stimuli as required, to prevent sensory deprivation

Older people

  • Interventions are similar, despite the age of development, although the incidence of confusion may be higher in older people
  • Keep in mind that older people can refer to fewer symptoms (for example, pain). Ensure to treat pain correctly