- Assess patient's LOC and changes in behavior to provide baseline for comparison with ongoing assessment findings.
Have a staff member stay at patient's bedside, if necessary, to protect patient from harm as long as patient is confused.
Enlist the aid of family member to help calm patient.- Limit noise and environmental stimulation to prevent patient from becoming more confused. Environmental stimulation tends to exacerbate confused states.
- Monitor neurologic status on a regular basis to detect any improvement or decline in patient's neurologic function.
- Use appropriate safety measures to protect patient from injury. Avoid physical restraints to prevent agitating patient.
- Address patient by name and tell your name to foster patient's awareness of self and environment.
- Give patient short, simple explanations each time you perform a procedure or task to decrease confusion.
- Schedule nursing care to provide quiet times for patient to help avoid sensory overload.
- Mention time, place, and date frequently throughout day. Have a clock and a calendar where patient can easily see them. Refer to these aids frequently when orienting patient to foster awareness of self and environment.
Keep patient's possessions in the same place as much as possible. A consistent, stable environment reduces confusion and frustration and aids completion of ADLs. - Ask family members to bring labeled family photos and other favorite articles to create a more secure environment for patient.
- Plan patient's routine and be as consistent as possible in following it. A consistent routine aids task completion and reduces confusion.
- Speak slowly, clearly, and allow patient ample time to respond to reduce frustration and promote task completion.
- Encourage patient to perform ADLs, dividing tasks into small, critical units. Be patient and specific in providing instructions. Allow time for patient to perform each task. These measures enhance self-esteem as well as help prevent complications related to inactivity.
- Encourage family members to share stories and discuss familiar people and events with patient. Sharing stories and familiar subjects promotes a sense of continuity, aids memory, and creates a sense of security and comfort. Note that even if patient's short-term memory is impaired, remote memory still may be intact.
- Support family members' attempts to interact with patient to provide positive reinforcement.
- Allow time before and after visits for family members to express feelings. Listening to family members in an open and nonjudgmental manner helps them cope with patient's illness. Listening to their opinions may also help you assess and monitor patient's condition.
- Reassure patient and family that confusion will be temporary to help relieve their anxiety. Always include patient in discussions.
Confer with physician about diagnostic test results, patient's progress in behavior, and patient's LOC. A collaborative approach to treatment helps ensure high-quality care and continuity of care.- Discuss episodes of acute confusion with patient and family members to make sure they understand the cause of confusion.
- Review supportive measures family members can take at home if patient begins to exhibit signs of confusion. Tell them to give patient short explanations of activities; repeat time, place, and date frequently; speak slowly and clearly and allow patient time to respond; and provide patient with a consistent routine. Teaching empowers patient and family members to take greater responsibility for their health care needs.
- Stress to patient and family that, in the future, they should inform health care providers about episodes of acute confusion to help ensure continuity of care.
Suggested NIC Interventions
Behavior Management: Overactivity/Inattention; Cognitive Stimulation; Delirium Management; Fall Prevention; Hallucination Management; Medication Management; Reality Orientation; Sleep Enhancement |