General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Encourage the family to relay correct information to the patient. This will reinforce comprehension for both the family and patient and promote open communication.
Inquire of family members if their information needs are being met. This action reinforces understanding by family members and assures them that the information/support they desire will be met. For example, “Do you have any questions about the care your mother is receiving or about her condition?”
Help family members use the information they receive to make health care decisions about the patient.
Family members may require assistance in processing information and applying it appropriately (e.g., regarding surgery, resuscitation, organ donation).
7
Nursing Diagnoses:
Acute Confusion/
Risk for Injury
related to age-related decreased physiologic reserve, renal function, or cardiac function; altered sensory/perceptual reception occurring with poor vision or hearing; or decreased brain oxygenation occurring with illness state and decreased functional lung tissue
Desired Outcomes:
The patient’s mental status returns to normal for the patient within 3 days of treatment. The patient sustains no evidence of injury or harm as a result of mental status.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s baseline level of consciousness (LOC) and mental status on admission. Obtain preconfusion functional and mental status abilities from significant other or clinical caregiver. Ask the patient to perform a three-step task. For example, “Raise your right hand, place it on your left shoulder, and then place the right hand by your right side.”
A component of the Mini-Mental Status Examination, this assessment of a three-step task provides a baseline for subsequent assessments of a patient’s confusion. A three-step task is complex and is a gross indicator of brain function.
Because it requires attention, it can also test for delirium.
Use the confusion assessment method (CAM) to help identify the presence or absence of confusion/delirium.
Delirium is a serious problem for hospitalized older adults and often goes unrecognized. The CAM tool (Waszynski, 2007) can be administered in a short period of time. CAM is a simple, standardized tool that can be used by bedside clinicians and has been validated in settings from medical-surgical areas to intensive care units. If your agency does not already employ this tool, there are several on-line sources that describe it in detail.
Test short-term memory by showing the patient how to use the call light, having the patient return the demonstration, and then waiting at least 5 min before having the patient demonstrate use of the call light again.
Document the patient’s actions in behavioral terms. Describe the
“confused” behavior.
Inability to remember beyond 5 min indicates poor short-term memory.
Identify the cause of acute confusion. Acute confusion is caused by physical and psychosocial conditions and not by age alone. For example, oximetry or arterial blood gas (ABG) values may reveal low oxygenation levels, serum glucose or fingerstick glucose may reveal high or low glucose level, and electrolytes and complete blood count (CBC) will ascertain imbalances and/or presence of elevated white blood cell (WBC) count as a determinant of infection. Hydration status may be determined by pinching skin over the sternum or forehead for turgor (tenting occurs with fluid volume deficit) and
Risk for Injury
Older Adult Care91
General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Assess for pain using a rating scale of 0-10. If the patient is unable to use a scale, assess for behavioral cues such as grimacing, clenched fists, frowning, and hitting. Ask the family or significant other to assist in identifying pain behaviors.
Acute confusion can be a sign of pain.
Treat the patient for pain, as indicated, and monitor behaviors. If pain is the cause of the confusion, the patient’s behavior should change accordingly.
Review cardiac status. Assess apical pulse and notify the health care provider of an irregular pulse that is new to the patient. If the patient is on a cardiac monitor or telemetry, watch for dysrhythmias; notify the health care provider accordingly.
Dysrhythmias and other cardiac dysfunctions may result in decreased oxygenation, which can lead to confusion.
Review current medications, including over-the-counter (OTC) drugs, with the pharmacist.
Toxic levels of certain medications, such as digoxin (rarely used), cause acute confusion. Medications that are anticholinergic also can cause confusion, as can drug interactions.
Monitor intake and output (I&O) at least q8h. Optimally, output should match intake. Dehydration can result in acute confusion.
Review the patient’s creatinine clearance test to assess renal function. Renal function plays an important role in fluid balance and is the main mechanism of drug clearance. Blood urea nitrogen (BUN) and serum creatinine are affected by hydration status and in older patients reveal only part of the picture. Therefore, to fully understand and assess renal function in older patients, creatinine clearance must be tested.
Have the patient wear glasses and hearing aid, or keep them close to the bedside and within easy reach for patient use.
Glasses and hearing aids are likely to help decrease sensory confusion.
Keep the patient’s urinal and other routinely used items within easy reach for the patient.
A confused patient may wait until it is too late to seek assistance with toileting.
If the patient has short-term memory problems, toilet or offer the urinal or bedpan q2h while awake and q4h during the night. Establish a toileting schedule and post it on the patient care plan and, inconspicuously, at the bedside.
A patient with a short-term memory problem cannot be expected to use the call light.
Check on the patient at least q30min and every time you pass the room.
Place the patient close to the nurses’ station if possible. Provide an environment that is nonstimulating and safe.
A confused patient requires extra safety precautions.
Provide music but not TV. Patients who are confused regarding place and time often think the
action on TV is happening in the room.
Attempt to reorient the patient to his or her surroundings as needed. Keep a clock with large numerals and a large print calendar at the bedside;
verbally remind the patient of the date and day as needed.
Reorientation may decrease confusion
Tell the patient in simple terms what is occurring. For example, “It’s time to eat breakfast,” “This medicine is for your heart,” “I’m going to help you get out of bed.”
Sentences that are more complex may not be understood.
Encourage the patient’s significant other to bring items familiar to the patient, including blanket, bedspread, and pictures of family and pets.
Familiar items may promote orientation while also providing comfort.
If the patient becomes belligerent, angry, or argumentative while you are attempting to reorient, stop this approach. Do not argue with the patient or the patient’s interpretation of the environment. State, “I can understand why you may [hear, think, see] that.”
This approach prevents escalation of anger in a confused person.
If the patient displays hostile behavior or misperceives your role (e.g., nurse becomes thief, jailer), leave the room. Return in 15 min. Introduce yourself to the patient as though you had never met. Begin dialogue anew.
Patients who are acutely confused have poor short-term memory and may not remember the previous encounter or that you were involved in that encounter.
continued
PART I: Medical-Surgical Nursing
If the patient attempts to leave the hospital, walk with him or her and attempt distraction. Ask the patient to tell you about the destination. For example, “That sounds like a wonderful place! Tell me about it.” Keep your tone pleasant and conversational. Continue walking with the patient away from exits and doors around the unit. After a few minutes, attempt to guide the patient back to the room. Offer refreshments and a rest. For example, “We’ve been walking for a while and I’m a little tired. Why don’t we sit and have some juice while we talk?”
Distraction is an effective means of reversing a behavior in a patient who is confused.
If the patient has a permanent or severe cognitive impairment, check on her or him at least q30min and reorient to baseline mental status as indicated; however, do not argue with the patient about his or her perception of reality.
Arguing can cause a cognitively impaired person to become aggressive and combative.
Note: Individuals with severe cognitive impairment (e.g., Alzheimer’s disease or dementia) also can experience acute confusional states (i.e., delirium) and can be returned to their baseline mental state.
If the patient tries to climb out of bed, offer a urinal or bedpan or assist to the commode.
The patient may need to use the toilet.
Alternatively, if the patient is not on bedrest, place him or her in chair or wheelchair at the nurses’ station.
This action provides added supervision to promote a patient’s safety while also promoting stimulation and preventing isolation.
Bargain with the patient. Try to establish an agreement to stay for a defined period, such as until the health care provider, meal, or significant other arrives.
This is a delaying strategy to defuse anger. Because of poor memory and attention span, the patient may forget he or she wanted to leave.
Have the patient’s significant other talk with the patient by phone or come in and sit with the patient if the patient’s behavior requires checking more often than q30min.
These actions by the significant other may help promote the patient’s safety.
If the patient is attempting to pull out tubes, hide them (e.g., under blankets). Put a stockinette mesh dressing over intravenous (IV) lines.
Tape feeding tubes to the side of the patient’s face using paper tape, and drape the tube behind the patient’s ear.
Remember: Out of sight, out of mind.
Evaluate the continued need for certain therapies. Such therapies may become irritating stimuli. For example, if the patient is now drinking, discontinue the IV line; if the patient is eating, discontinue the feeding tube; if the patient has an indwelling urethral catheter, discontinue the catheter and begin a toileting routine.
Use restraints with caution and according to agency policy. Patients can become more agitated when wrist and arm restraints are used.
Use medications cautiously for controlling behavior. Follow the maxim “start low and go slow” with medications because older patients can respond to small amounts of drugs.
Neuroleptics, such as haloperidol, can be used successfully in calming patients with dementia or psychiatric illness
(contraindicated for individuals with parkinsonism). However, if the patient is experiencing acute confusion or delirium, short-acting benzodiazepines (e.g., lorazepam) are more effective in reducing anxiety and fear. Anxiety or fear usually triggers destructive or dangerous behaviors in acutely confused older patients.
Note: Neuroleptics can cause akathisia, an adverse drug reaction evidenced by increased restlessness.
Also see Chapter 97, “Dementia—Alzheimer’s Type,” p. 716, as appropriate.