ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: INDEPENDENT:
Chronic 1. Place an 1. Patients with
1. Lack of Confusion as identification chronic
evidenced by bracelet on confusion
motivation to
continuous the patient. may wander
initiate and/or hallucinations, 2. Avoid and can
follow through fluctuations of exposing the become lost;
with goal- psychomotor patient to identification
directed or activity, level of unusual bracelets
purposeful consciousness, situations and increase
behavior agitations and people as patient safety.
sleep-wake much as 2. Situational
2. Fluctuation in
cycle, and possible. anxiety
psychomotor misperceptions. Maintain associated
activity continuity of with
(tremors, body caregivers. environmental
movement) Maintain ,
3. Misperceptions routines of interpersonal,
4. Fluctuation in care through or structural
established change can
cognition
mealtimes, intensify into
5. Increased bathing, and disturbed
agitation or sleeping behavior.
restlessness schedules. 3. Any
6. Fluctuation in Send a extraneous
level of familiar person noise and
consciousness with a patient stimuli can be
when the misinterprete
7. Fluctuation in
patient goes d by the
sleep-wake for diagnostic confused
cycle testing or into patient.
8. Hallucinations unfamiliar Images on
(visual/auditory environments. walls may be
) 3. Provide a threatening
calm for the
 environment. patient.
4. Promote 4. Orientation to
reality- one’s
oriented environment
relationships increases
and one’s ability
environment to trust others
(e.g., display 5. Familiar
clocks, personal
calendars, possessions
personal increase the
items, patient’s
seasonal comfort level.
decorations). 6. This method
5. Encourage the can reduce
patient to anxiety.
check the Saying “stay
calendar and sitting on the
clock often to chair” is more
orient himself positive than
or herself. saying “Don’t
6. Talk to the get up.”
patient using 7. Sensory
simple, overload can
concrete result in
nouns in agitated
positive terms. behavior in a
7. Keep the patient with
environment chronic
quiet and non- confusion.
stimulating; Misinterpretati
avoid using on of the
buzzers and environment
alarms if can also
possible. contribute to
Reduce sights agitation.
 and sounds 8. This can be
that have a threatening
high potential for the patient
for and can result
misinterpretati in a defensive
on such as reaction.
buzzers, 9. Patients can
alarms, and sense
overhead feelings of
paging compassion.
systems. A calm, slow
8. Avoid manner
challenging projects a
illogical feeling of
thinking. comfort to the
9. Approach patient.
patient with a 10. Confused
caring, patients are
friendly, and incapable to
accepting follow
attitude and complicated
talk calmly instructions;
and slowly. breaking
10. Break down down an
self-care tasks activity into
into simple simple steps
steps. makes
completing
DEPENDENT: the activity
11. Administer more
medication achievable.
ordered by the 11. Medications
assigned will help for
psychiatrist or fast recovery
physician. of the patient
depending o
 the medicine
prescribed.
12. A confused
COLLABORATIV patient may
E: not
12. Allow family completely
members to understand
orient the what is
patient about happening.
current news Increased
and family orientation
events. promotes a
13. Encourage greater
family to make degree of
use of support safety for the
groups or patient.
other service 13. Community
programs. resources
14. Refer to a provide
Psychiatrist. support,
assist with
problem-
solving, and
reduce the
demands
associated
with
caregiving.
14. For faster
recovering of
the patient
and to also
determine
futher risk
and
complications
 .

Nursing Interventions Rationale

Patients with chronic confusion may

wander and can become lost;
Place an identification bracelet on the patient.
identification bracelets increase
patient safety.

Prevent further deterioration and maximize level of function:

 Avoid exposing the patient to unusual situations and

people as much as possible. Maintain continuity of
Situational anxiety associated with
caregivers. Maintain routines of care through
environmental, interpersonal, or
established mealtimes, bathing, and sleeping
structural change can intensify into
schedules. Send a familiar person with a patient
disturbed behavior.
when the patient goes for diagnostic testing or into
unfamiliar environments.
Any extraneous noise and stimuli can
be misinterpreted by the confused
 Provide a calm environment.
patient. Images on walls may be
threatening for the patient.
 Promote reality-oriented relationships and
Orientation to one’s environment
environment (e.g., display clocks, calendars,
increases one’s ability to trust others.
personal items, seasonal decorations).
 Encourage the patient to check the calendar and Familiar personal possessions
clock often to orient himself or herself. increase the patient’s comfort level.
This method can reduce anxiety.
 Talk to the patient using simple, concrete nouns in Saying “stay sitting on the chair” is
positive terms. more positive than saying “Don’t get
up.”
 Allow family members to orient the patient about A confused patient may not completely
 understand what is happening.
Increased orientation promotes a
current news and family events.
greater degree of safety for the
patient.
 Keep the environment quiet and nonstimulating; Sensory overload can result in
avoid using buzzers and alarms if possible. Reduce agitated behavior in a patient with
sights and sounds that have a high potential for chronic confusion. Misinterpretation of
misinterpretation such as buzzers, alarms, and the environment can also contribute to
overhead paging systems. agitation.
This can be threatening for the patient
 Avoid challenging illogical thinking.
and can result in a defensive reaction.
Patients can sense feelings of
 Approach patient with a caring, friendly, and compassion. A calm, slow manner
accepting attitude and talk calmly and slowly. projects a feeling of comfort to the
patient.
This promotes a sense of
 Promote participation in resocialization groups.
responsibility and independence.
 Ensure that the patient is in a safe environment by Patients with chronic confusion lose
eliminating possible hazards such as pointed objects the ability to make good judgments
and harmful liquids. and can easily harm self or others.
Depending on the cause, long-term
 Allow the patient to reminisce, existing in his or her
memory is usually retained longer than
own reality if not detrimental to the patient’s well-
short-term memory. This approach
being.
can be enjoyable for the patient.
Involving the patient in safe, repetitive
activities occupies the patient’s mind
and hands. The activities may reduce
Provide repetitive hand activities.
agitation and provide release of
energy (e.g., fold and refold towels
and washcloths).
People with chronic confusion need
Present one simple direction at a time and repeat as
time to understand and interpret
necessary.
directions.
 Confused patients are incapable to
follow complicated instructions;
Break down self-care tasks into simple steps. breaking down an activity into simple
steps makes completing the activity
more achievable.
The noise and confusion in a large
Let the patient eat in a peaceful environment with a smaller dining room can be overwhelming for
number of people. a confused patient and can result in
agitated behavior.
Feeding oneself is a complicated task
Give finger food if the patient has difficulty using eating utensils
and may prove challenging for
or if unable to sit to eat.
someone with chronic confusion.
Help the family and significant others in developing coping
strategies.
The family members need to let the
 Determine family members’ resources and their
patient do all that he or she is able to
availability and eagerness to participate in meeting
do. This approach will maximize the
the patient’s needs.
patient’s level of functioning.
 Refer family to social services or other supportive To assist with meeting the demands of
services. caregiving for older patients.
Community resources provide support,
 Encourage family to make use of support groups or assist with problem-solving, and
other service programs. reduce the demands associated with
caregiving.
Validation lets the patient understand
 Validate the family members’ feelings with regard to that the nurse has heard and realizes
the impact of patient behavior on family lifestyle. what was said, and it improves the
nurse-patient relationship.
 Encourage family to include patient in family
activities when desirable.