Date post: | 26-Mar-2015 |
Category: |
Documents |
Upload: | kaylee-farrell |
View: | 234 times |
Download: | 2 times |
1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Chapter 22
Confusion
2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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.
3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Interventions: Delirium
10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 22-1
12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 22-2
16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Interventions: Dementia
18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Self-Care Deficit
19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 22-3
24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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
27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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