Download Chapter_022_LO

Chapter 22
Confusion
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
1
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.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
2
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
3
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
4
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
5
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 CreutzfeldtJakob disease
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
6
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
7
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
8
Interventions: Delirium
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
9
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
10
Figure 22-1
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
11
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
12
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
13
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
14
Figure 22-2
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
15
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
16
Interventions: Dementia
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
17
Self-Care Deficit
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
18
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
19
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
20
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
21
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
22
Figure 22-3
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
23
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
24
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
25
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
26
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
27