Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to acute confusion.
1. Identify contributing factors/conditions.Acute confusion is a symptom. Uncovering the cause of acute confusion is necessary in order to treat it. Recent surgery, infection, trauma/head injury, medication reactions, exposure to toxic chemicals are a few common causes, however a broad range of situations and conditions can cause acute confusion.
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2. Consider substance abuse or withdrawal.The overuse of alcohol and drugs can cause confusion from a depressed CNS. Withdrawal from substances also causes delirium and other related symptoms such as agitation, hallucinations, and seizures if not identified and treated in a timely manner.
3. Monitor vital signs closely.Physiological causes of confusion can have detrimental effects if not treated promptly. Hypoxia, for example, is a lack of oxygen delivery to the tissues. If the brain is lacking in oxygen, confusion will occur. Other symptoms on assessment may be tachycardia and a low oxygen saturation level.
4. Determine recent medication use.This can be confirmed through lab work for some medications such as benzodiazepines, anticonvulsants, narcotics, lithium, and more. Overuse of these medications can cause toxicity and central nervous depression.
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5. Identify baseline cognition.If family or support systems are available, assess what the patient’s usual baseline cognition level is or compare to earlier assessments if confusion is a new finding. Family may also be able to help identify causative factors.
6. Assess for a psychiatric history.The patient may be experiencing an exacerbation of their mental illness. This can include schizophrenia or bipolar disorder. Patients with Alzheimer’s disease may experience “sundowning” which is acute confusion that occurs later in the day.
7. Monitor lab values.If an infection is present this will be seen through blood cultures and complete blood counts. A urinalysis can pinpoint a urinary tract infection which causes confusion in older patients. High ammonia levels in those with liver disease result from a buildup of waste products in the blood, leading to confusion. High or low glucose levels can cause confusion. Low sodium levels can cause confusion and worsen into seizures.
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