Acute confusion is an abrupt disruption in consciousness, attention, cognition, and perception. It is reversible and is a symptom of an underlying condition. Causes can range in severity and pinpointing the precipitating factor is important in order to treat the patient and improve confusion.
The nurse’s role in acute confusion is to first ensure patient safety. Patients experiencing hallucinations, decreased consciousness, paranoia or anxiety are a safety risk to themselves and others. Along with implementing treatment and assessing for new or worsening confusion the nurse applies therapeutic interventions to relax the patient and provide a calming environment.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are the common causes of acute confusion:
- Increased risk when age over 60 years
- Dementia
- Hypoxemia
- Alcohol or substance abuse
- Reaction to a medication/anesthesia
- Sleep deprivation
- High fever
- Seizures
- Trauma/head injury
- Hypoglycemia
- Stroke or transient ischemic attack
- Surgery
Signs and Symptoms (As evidenced by)
The following are the common signs and symptoms of acute confusion. They are categorized into subjective and objective data based on patient reports and the assessment by the nurse.
Subjective (Patient reports)
- Hallucinations
- Paranoia
Objective (Nurse assesses)
- Fluctuation in cognition/consciousness
- Agitation/restlessness
- Inappropriate perceptions
- Lack of understanding or follow-through with tasks
- Tremors
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for acute confusion:
- Underlying cause treated when possible.
- Patient will regain orientation to person, place, time, and situation with an appropriate level of consciousness.
- Patient will initiate lifestyle changes to prevent reoccurrence of acute confusion/delirium.
- Patient will verbalize contributing factors of fluctuations in cognition.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to acute confusion.
1. Identify contributing factors/conditions.
Acute confusion is a symptom. Uncovering the cause of acute confusion is necessary in order to treat it. Recent surgery, infection, trauma/head injury, medication reactions, exposure to toxic chemicals are a few common causes, however a broad range of situations and conditions can cause acute confusion.
2. Consider substance abuse or withdrawal.
The overuse of alcohol and drugs can cause confusion from a depressed CNS. Withdrawal from substances also causes delirium and other related symptoms such as agitation, hallucinations, and seizures if not identified and treated in a timely manner.
3. Monitor vital signs closely.
Physiological causes of confusion can have detrimental effects if not treated promptly. Hypoxia, for example, is a lack of oxygen delivery to the tissues. If the brain is lacking in oxygen, confusion will occur. Other symptoms on assessment may be tachycardia and a low oxygen saturation level.
4. Determine recent medication use.
This can be confirmed through lab work for some medications such as benzodiazepines, anticonvulsants, narcotics, lithium, and more. Overuse of these medications can cause toxicity and central nervous depression.
5. Identify baseline cognition.
If family or support systems are available, assess what the patient’s usual baseline cognition level is or compare to earlier assessments if confusion is a new finding. Family may also be able to help identify causative factors.
6. Assess for a psychiatric history.
The patient may be experiencing an exacerbation of their mental illness. This can include schizophrenia or bipolar disorder. Patients with Alzheimer’s disease may experience “sundowning” which is acute confusion that occurs later in the day.
7. Monitor lab values.
If an infection is present this will be seen through blood cultures and complete blood counts. A urinalysis can pinpoint a urinary tract infection which causes confusion in older patients. High ammonia levels in those with liver disease result from a buildup of waste products in the blood, leading to confusion. High or low glucose levels can cause confusion. Low sodium levels can cause confusion and worsen into seizures.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with acute confusion.
1. Orient the patient as necessary.
Continuous and frequent reorienting may be necessary to prevent agitation and fear. Reorient to staff, surroundings, environment, and procedures. Do not challenge illogical thinking as this can worsen delirium and anxiety.
2. Implement safety measures.
Patient safety is a top priority. Patients who are restless or paranoid due to confusion may behave in unsafe ways. Keep the bed in a low position with the alarm on, and the call bell within reach to prevent falls. 1:1 precautions with a sitter may be necessary for suicidal tendencies or patients who are prone to falls.
3. Treat drug or alcohol withdrawal.
Alcohol withdrawal is assessed and treated with benzodiazepines based on the patient’s symptoms of nausea and vomiting, tremor, sweating, anxiety, agitation, headache, orientation, or any hallucinations.
4. Treat underlying physiological conditions.
Infection/sepsis is treated with antibiotics. Discontinue medications that cause an adverse reaction. Correct abnormal electrolyte imbalances. Treat high or low blood glucose.
5. Limit stimuli.
Overstimulation can worsen confusion, anxiety, and agitation. Keep the room quiet and eliminate noise such as the TV. Provide undisturbed rest periods. Allow family to visit only if it comforts the patient.
6. Prevent sundowning.
Maintain a routine for waking, meals, bedtime, and activities. Provide plenty of exposure to light. Limit daytime napping. Provide familiar items such as photographs or blankets.
7. Reduce polypharmacy.
The overuse of similar medications or the interactions between medications can interfere with cognition. Confer with the healthcare provider in eliminating or simplifying medication regimens.
8. Ensure appropriate support at discharge.
Discuss with case management regarding safety needs at home. This may include home health to ensure proper medication management, family support to monitor seizures, and drug or alcohol abuse treatment programs.
9. Educate on causes and symptoms to prevent a recurrence.
Teach patients to monitor for symptoms before delirium occurs. Alterations in blood glucose often begin with headaches, sweating, and faintness. Keep pain controlled before it becomes unbearable. Older adults at risk for UTIs should be taught how to prevent them such as proper hygiene and drinking plenty of fluids.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for acute confusion.
Care Plan #1
Diagnostic statement:
Acute confusion related to sepsis secondary to pneumonia, as evidenced by increased agitation and hallucinations.
Expected outcomes:
- Patient will not exhibit a decreased level of consciousness.
- Patient will have diminished episodes of delirium as evidenced by the following indicators:
- Remain calm
- Participate in ADLs or other nursing activities.
- Be less combative.
- Patient will not report any psychotic manifestations.
- Patient will remain free from injury
Assessment:
1. Assess mental status (i.e., alertness, attention span, orientation, speech, i.e.)
These symptoms suggest cognitive decline and must be addressed promptly.
2. Perform Confusion Assessment Method (CAM) for delirium.
CAM is a standardized evidence-based screening tool that aids non-psychiatric health personnels to identify delirium quickly and accurately.
3. Monitor laboratory results.
Sepsis can progress to shock, compromising systemic tissue perfusion. Hypoxemia and hypercarbia shown in arterial blood gas results and pulse oximetry findings accompanied by a deteriorating level of consciousness may indicate alterations in cerebral blood flow.
Interventions:
1. Administer antibiotics as prescribed.
Pneumonia is the underlying etiology of sepsis that leads to acute confusion. Treating the underlying infection addresses sepsis and, ultimately, the psychological manifestations.
2. Administer fluids and electrolytes as indicated.
Sepsis causes systemic vasodilation that compromises systemic circulation. Adequate fluid resuscitation optimizes perfusion, especially in the brain.
3. Establish a calm environment by modulating sensory exposure, eliminating excessive noise, and using appropriate lighting based on the time of day.
Noise levels in the hospital, often from staff conversation and other avoidable sources, are higher than recommended and lead to significant sleep loss causing agitation.
4. Anticipate the need for antipsychotic medications as prescribed.
Recognize that delirium is frequently treated with antipsychotic drugs or sedatives; if there is no other way to keep the client safe, administer these medications cautiously, as ordered while monitoring for medication side effects.
5. Refer the patient to a psychiatrist as needed.
Therapy initiated by psychiatric experts may be needed in case the worsening of psychotic behaviors occurs.
6. Provide reality orientation.
Patients with delirium may experience altered states in reality. Reality orientation helps in improving the psychomotor and cognitive function of confused patients.
Care Plan #2
Diagnostic statement:
Acute confusion related to head trauma as evidenced by fluctuation in cognition and consciousness.
Expected outcomes:
- Patient will not have a Glasgow coma score of less than 13.
- Patient will be oriented to time, place, and person.
Assessment:
1. Assess imaging modality findings.
Imaging modalities such as head x-ray, CT scan, and MRI provide the severity and location of head trauma. Hence, the nurse can correlate the site of the injury with the presenting cognitive signs and symptoms of the patient. This helps in anticipating the needs of the patient.
2. Monitor for signs of increased intracranial pressure (ICP).
Watch out for headaches, blurred vision, confusion, hypertension, projectile vomiting, changes in behavior, shallow breathing, etc., all signs and symptoms of increased ICP. Increased ICP can occur in head trauma, producing a space-occupying lesion that alters cerebral perfusion and compromises cognitive function.
3. Monitor neuro vital signs.
Vital signs (especially BP) with neuro physical examination monitoring help identify a deteriorating cognitive function early.
Interventions:
1. Elevate the head of the bed at 30 degrees and maintain the head in midline.
This improves cerebral venous drainage optimizing cerebral perfusion.
2. Anticipate the need for endotracheal intubation.
Deteriorating level of consciousness (GCS: <8), impaired gas exchange (i.e., apnea, hypercapnia, hypoxia), or patients who cannot protect their airways are considerations for endotracheal intubation.
3. Ensure temperature control. Avoid hyperthermia
Fever increases cerebral metabolic demand and ICP.
4. Provide clocks and calendars, encourage the family to visit regularly, and bring familiar objects from home.
Persons at risk for delirium should be provided clocks and calendars for reorientation; family, friends, and familiar objects may help with reorientation.
5. Provide cognitive stimulation.
Daily cognitive stimulation can prevent cognitive decline and promote mental recovery.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Alcohol and Drug Withdrawal. (n.d.). Permanente Medicine. https://mydoctor.kaiserpermanente.org/mas/structured-content/Health_Topic_Alcohol_and_Drug_Withdrawal_-_Addiction_Med.xml
- 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/
- Bokhari, A.M. (2023). Bacterial sepsis. Medscape. https://emedicine.medscape.com/article/234587-overview
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- 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.
- 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.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- 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
- 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
- Shaikh, F.& Waseem, M. (2022). Head trauma. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430854/
