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Chapter 22

Confusion

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Learning Objectives

• Define delirium and dementia.• Identify the causes of acute confusion.• Explain the differences between delirium and

dementia.• Discuss nursing assessment and interventions

related to delirium and dementia.

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Delirium

• Definition: short-term confusional state with sudden onset and is typically reversible

• Characterized by disturbances in consciousness that impair a person’s awareness of the environment

• May have difficulty focusing or paying attention, so easily distracted

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Delirium

• May be difficult to engage in a conversation, and questions often must be repeated several times

• Impaired recent memory is common, along with disorientation and language problems

• Speech may be slurred and disjointed, with aimless repetitions

• May misinterpret what is going on in the environment; may develop delusional thinking and experience hallucinations

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Delirium

• May alternate between hyperactivity and hypoactivity

• May fluctuate from drowsiness to stupor or coma

• Conversely, may be very alert and agitated • Other symptoms: anxiety, depression,

irritability, anger, apathy, or euphoria • Acute confusion begins abruptly and usually

lasts a short time: as long as a week, but rarely more than a month

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Dementia

• Chronic and irreversible; memory impairment and many other cognitive deficits

• Impaired intellectual function, problem-solving ability, judgment, memory and orientation, and inappropriate behavior

• Several types of dementia• Alzheimer’s disease, vascular dementia, Pick’s

disease, Huntington’s disease, and Creutzfeldt-Jakob disease

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Dementia

• Other conditions associated with dementia • Normal pressure hydrocephalus, subdural

hematoma, brain tumors, neurosyphilis, and acquired immunodeficiency syndrome (AIDS)

• Dementia not a disease but a clinical syndrome: collection of symptoms that can occur with many types of diseases

• Vascular dementia results from damage to brain cells caused by inadequate blood supply

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Assessment

• Observe behavior and collect data about orientation, memory, and sleep habits

• Family may provide information if patient cannot • Ask when the symptoms of confusion started and

whether confusion is constant or intermittent • List acute or chronic illnesses and all medications

patient has been taking (including home remedies and over-the-counter drugs)

• Assessment data help physician determine if patient is suffering from delirium or dementia

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Interventions: Delirium

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Disturbed Thought Processes

• Private room with continual supervision • Room quiet and uncluttered to avoid agitation

caused by extraneous stimuli • Lighting soft and diffuse to avoid shadows that

may be misinterpreted and add to patient’s fears

• Familiar objects, such as pictures, a clock, and a large calendar, placed in the room can help orient the patient to time and person

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Figure 22-1

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Disturbed Thought Processes

• Communication with a confused patient should be simple and direct

• Anyone dealing with a delirious patient should be calm, warm, and reassuring

• It is helpful if the same personnel are assigned to care for the patient

• Avoid sudden movements, and handle the patient gently during procedures or turning

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Disturbed Thought Processes

• Hallucinating patients need one-to-one nursing observation and repeated verbal reorientation

• Need to be assured that the medical and nursing staff are helping them and keeping them safe

• Frequent orientation to the surroundings and the situation is important

• Keep choices to a minimum • Simple, direct statements better than questions

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Disturbed Sleep Pattern

• Sleep deprivation can cause or contribute to disorientation and confusion

• A backrub, glass of warm milk, and a soothing conversation may help the patient relax and fall asleep

• Schedule medications or treatments at times that do not interrupt nighttime sleep

• Presence of a family member may help calm an agitated and confused patient

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Figure 22-2

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Risk for Injury

• Patient may pull on tubes, try to get out of bed unassisted, or attempt to leave the setting

• Avoid physical restraints: increase anxiety and agitation in confused patients; can result in injuries

• Ask a family member to remain with the patient or assign a staff member to do so

• Avoid arguing with delirious patients • Gently explain what you are doing and why

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Interventions: Dementia

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Self-Care Deficit

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Imbalanced Nutrition: Less Than Body Requirements

• Assist with meals: cutting food or total feeding • Foods that can be managed with a single utensil may

facilitate self-feeding • Finger foods high in protein and carbohydrates allow

patients to feed themselves more easily • Small, frequent meals less confusing to patients.

Remove distractions from the eating area • Group meals may be helpful because patients often

imitate behaviors of others • Offer fluids frequently during the day

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Disturbed Sleep Pattern

• Sleep and awakening are often reversed• Try to keep them awake during the day and get them

to sleep at night • Tests and treatments can be scheduled during the

morning and early afternoon to allow the patients time to wind down by bedtime

• Some caregivers have found that a quiet hour in the afternoon with soft music promotes sleep at night

• Patients who awaken during the night and become confused and agitated should be reassured in a soft, soothing manner

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Risk for Injury

• A safe, structured environment is essential for a person with dementia

• Nothing should be left around that could harm the patient

• Falls and injuries may be prevented with careful observation, muscle strengthening, and a fall prevention program

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Disturbed Thought Processes/Impaired Verbal

Communication• Communication should be simple and direct • Patients must be approached gently, calmly, and

quietly• Nonverbal communication is extremely important • Look for cues from actions and facial expressions

because patients often are not able to express their needs verbally

• When patients resist activities such as bathing or dressing, avoid confrontations

• A consistent schedule of care given by the same caregivers provides security for a dementia patient

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Figure 22-3

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Nursing Care

• Guidelines for working with dementia patients• They usually forget things relatively quickly• They are usually unable to learn new things

• You can be creative in the care of dementia patients by using these two concepts

• Sometimes agitation indicates pain, hunger, stress, fear, or the need for toileting

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Nursing Care

• Cognitive developmental approach (CDA) • Adapts interventions based on cognitive abilities• It is thought to reduce patient stress and frustration

by eliminating unrealistic expectations and allowing the patient to do as much as able

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CDA: Principles

• Accept that the patient may no longer be able to make adult decisions and behave as a healthy adult would. Offer limited choices to simplify decision making

• Adapt the environment to the patient rather than trying to adapt the patient to the environment

• Encourage self-care at whatever level the patient can function. If the patient can eat independently with the hands but not with utensils, provide finger foods

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CDA: Principles

• Recognize irrational fears and arrange alternative ways to give personal care

• In advanced dementia, patient behaviors and thinking are not typical of a healthy adult. Some strategies that work with children often work with dementia patients

• Recognize that patient deserves to be treated with dignity regardless of abilities or behaviors. Even the most impaired patient can probably sense compassion in a caregiver