Nursing Diagnosis: Chronic Confusion

Kimberly Hickey, Betty J. Ackley, and Nancy English

NANDA Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and
personality characterized by a decreased ability to interpret environmental stimuli and a decreased
capacity for intellectual thought processes, which manifest as disturbances of memory, orientation,
and behavior

Defining Characteristics: Altered interpretation/response to stimuli; clinical evidence of organic

impairment; altered personality; impaired memory (short and long term); impaired socialization; no
change in level of consciousness

Related Factors: Multi-infarct dementia; Korsakoff's psychosis; head injury; Alzheimer's disease;
cerebrovascular accident

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Cognitive Orientation

Information Processing

Memory

Neurological Status: Consciousness

Client Outcomes

Remains content and free from harm

Functions at maximal cognitive level

Participates in activities of daily living at the maximum of functional ability

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Dementia Management

Environmental Management

Reality Orientation

Surveillance: Safety

Nursing Interventions and Rationales

Determine client's cognitive level using a screening tool such as the Mini Mental State
Exam (MMSE). Using a standard evaluation tool such as the MMSE can help determine the
client's abilities and assist with planning appropriate nursing interventions (Agostinelli et
al, 1994; Espino et al, 1998).
 Gather information about client pre-dementia functioning, including social situation,
physical condition, and psychological functioning. Knowing the client's background can help
the nurse identify agenda behavior and use validation therapy, which will provide guidance
for reminiscence. Background information may help the nurse to understand clients
behavior if client becomes delusional and hallucinates.

Assess the client for signs of depression: insomnia, poor appetite, flat affect, and
withdrawn behavior. As much as 50% of clients with dementia have depressive symptoms
(Cleeland, 1997).

Ensure that client is in a safe environment by removing potential hazards such as

sharp objects and harmful liquids. Clients with dementia lose the ability to make good
judgments and can easily harm self or others.

Place an identification bracelet on client. Clients with dementia wander and can
become lost; identification bracelets increase client safety.

Avoid exposing client to unfamiliar situations and people as much as possible. Maintain
continuity of caregivers. Maintain routines of care through established mealtimes, bathing,
and sleeping schedules. Send familiar person with client when client goes for diagnostic
testing or into unfamiliar environments. Situational anxiety associated with environmental,
interpersonal, or structural change can escalate into agitated behavior (Gerdner,
Buckwalter, 1994).

Keep environment quiet and nonstimulating; avoid using buzzers and alarms if
possible. Minimize sights and sounds that have a high potential for misinterpretation such
as buzzers, alarms, and overhead paging systems. Sensory overload can result in agitated
behavior in a client with dementia. Misinterpretation of the environment can also
contribute to agitation.

Begin each interaction with client by identifying self and calling client by name.
Approach client with a caring, loving, and accepting attitude and speak calmly and slowly.
Dementia clients can sense feelings of compassion. A calm, slow manner projects a feeling
of comfort to the client (Stolley, 1994).

Touch client gently, stroking hand or arm in a soothing fashion if acceptable in client's
culture.

Give one simple direction at a time and repeat as necessary. Use verbal and physical
prompts, and model the desired action if needed and possible. People with dementia need
time to assimilate and interpret your directions. If you rephrase your question, you give
them something new to process, increasing their confusion (Stolley, 1994).

Break down self-care tasks into simple steps (e.g., instead of saying, "Take a shower,"
say to client, "Please follow me. Sit down on the bed. Take off your shoes. Now take off
your socks."). Dementia clients are unable to follow complex commands; breaking down
an activity into simple steps makes completing the activity more feasible (Agostinelli et al,
1994).

Keep questions simple; yes or no questions are often preferable to open-ended

questions. Use positive statements and actions and avoid negative communication.
Negative feedback leads to increased confusion and agitation. It is more effective to go
along with the client and then redirect as necessary.
 If eating in the dining room causes increased agitation, let client leave and eat in a
quieter environment with a smaller number of people. The noise and confusion in a large
dining room can be overwhelming for a dementia client and can result in agitated
behavior. It is preferable to have dementia clients eat in small groups (Sloane, 1998).

Provide finger food if patient has difficulty using eating utensils or if unable to sit to
eat. Feeding oneself is a complex task and may prove challenging for someone with
significant dementia (Finley, 1997).

Provide boundaries by placing red or yellow tape on the floor or by using a stop sign.
Boundaries help the client identify safe areas; older clients can more easily see red and
yellow than other colors.

Assess the etiology of wandering before or rather than attempting to control the
wandering. Wandering indicates a problem and need for intervention; therefore the reason
for the wandering behavior needs to be determined (Algase, 1999).

Write client's name in large block letters in the room and on client's clothing and
possessions. Use symbols rather than words to identify areas such as the bathroom or
kitchen.

Limit visitors to two and provide them with guidelines on appropriate topics to discuss
and how to best communicate with client. (See Client/Family Teaching for how to converse
with a memory-impaired person.)

Set up scheduled quiet periods in a recliner or room. Use blankets and other
environmental cues to define rest periods. Quiet times allow the client's anxiety and
building tension levels to decrease (Hall et al, 1995). Fatigue has been associated with the
onset of increased confusion and agitation (Stolley, 1994).

Provide quiet activities, such as listening to classical or religious music, or other cues
that promote relaxation in the afternoon or early evening. An increase in confusion and
agitation, referred to as sundowning syndrome, may occur in the late afternoon and early
evening. Quiet activities can provide a calming environment.

Provide simple activities for the client, such as folding washcloths and sorting or
stacking activities. Avoid misleading and frightening stimuli, which may include television,
mirrors, and pictures of people or animals. Repetitive activities give the client with
dementia a positive outlet for behavior (Burgener et al, 1998). Dementia clients see, hear,
and perceive a different world than other people. They may not recognize themselves in
the mirror and be afraid of the stranger they see so close to them.

Consider using doll therapy. Ask family members to bring a large, safe doll or stuffed
animal such as a teddy bear. Doll therapy can be soothing to some dementia clients
(Bailey, 1992; Paulanka, Griffin, 1993).

If client becomes increasingly confused and agitated, perform the following steps:

o Monitor client for physiological causes, including acute hypoxia, pain, medication
effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte
disturbances, and constipation. An acute change in behavior is a medical emergency
and should be evaluated. Many physiological factors can result in increased agitation
of clients with dementia (Gerdner, Buckwalter, 1994; Alexopoulos et al, 1998).
 o Monitor for psychological causes, including changes in environment, caregiver, and
routine; demands to perform beyond capacity; and multiple competing stimuli
(including discomfort). It is important for the nurse to recognize precipitating events
and subsequent behavior to prevent furthers incidents of agitation (Bair et al, 1999).

o Avoid confrontations with the client; allow client to dissipate energy by performing
repetitive tasks or by pacing.

If client is delusional or hallucinating, do not confront him or her with reality. Use
validation therapy to verbally reflect back the emotions that the client appears to be
experiencing. Use statements such as, "It must be frightening to see a fire at the end of
your bed," "I can see that you are afraid," "I will stay with you," or "Can you tell me more
about what is going on right now?" Orienting the client to reality can increase agitation;
validation therapy conveys empathy and understanding and can help determine the
internal stimulus that is creating the change in behavior (Feil, 1993). In one study, training
in validation therapy for staff resulted in decreased doses of psychotherapeutic
medications and incidences of behavior problems (Fine, Rouse-Bane, 1995).

Decrease stimuli in the environment (e.g., turn off television, take client to a quiet
place). Institute activities associated with pleasant emotions, such as playing soft music
the client likes, looking through a photo album, providing favorite food, or using simulated
presence therapy. Decreasing stimuli can decrease agitation. Reassuring activities, such as
simulated presence therapy wherein client listens to a tape of a loved one's phone
conversation, can help bring about pleasant emotions that soothe the client (Woods,
Ashley, 1995).

Avoid using restraints if at all possible. Restraints are not benign interventions and
should be used sparingly and judiciously only when alternatives to manage the behaviors
have been tried and been unsuccessful. Side effects include falls, increased confusion,
deconditioning, and incontinence (Tinetti, Liu, Ginter, 1992).

Use prn or low dose regular dosing of psychotropic or antianxiety drugs only as a last
resort. They are effective in managing symptoms of psychosis and aggressive behavior.
Start with the lowest possible dose. Psychotropic drugs such as haloperidol (Haldol) and
resperidone (Risperdol) may decrease client function and have side effects that need to be
monitored (Katz et al, 1999).

Avoid use of anticholinergic medications such as Benadryl. Anticholinergic medications

have a high side effect profile that includes disorientation, urinary retention, and excessive
drowsiness (Nurses Drug Alert, 1995). The anticholinergic side effects outweigh the
antihistaminic effects.

For predictable difficult times, such as during bathing and grooming, try the following:

o Massage the client's hands lovingly or use therapeutic touch to relax the client. Hand
massage and therapeutic touch have been shown to induce relaxation that may allow
care activities to take place without difficulty (Snyder, Egan, Burns, 1995).

o Use positive behavioral reinforcement for each of the small steps involved in bathing,
such as praising client for walking toward the shower, sitting in the shower chair, and
removing items of clothing. Positive behavioral reinforcement for desired behavior is
effective for clients with dementia (Boehm et al, 1995). Consider a towel bath if
shower or tub bathing is too stressful for client (Hall, Buckwalter, 1999).

o Treat the client with the utmost respect and give individualized care. Treating
confused clients with respect and individualizing care can decrease aggression and
increase nursing staff satisfaction (Maxfield, Lewis, Cannon, 1996).
 For early dementia clients with primarily symptoms of memory loss, see care plan for
Impaired Memory. For clients with self-care deficits, see appropriate care plan (Feeding
Self-care deficit, Dressing/grooming Self-care deficit, Toileting Self-care deficit).
Geriatric
NOTE: Most of the preceding interventions apply to the geriatric client.

Use reminiscence and life review therapeutic interventions; ask questions about
client's work, child rearing, or time spent in the service. Ask questions such as "What was
really important to you as you look back?" Reminiscence and life review can help an older
person reframe and accept life events (Burnside, Haight, 1994).
Multicultural

Assess for the influence of cultural beliefs, norms, and values on the family or
caregiver understanding of chronic confusion or dementia. What the family considers
normal and abnormal health behavior may be based on cultural perceptions (Leininger,
1996).

Inform client family or caregiver of the meaning of and reasons for common behavior
observed in clients with dementia. An understanding of dementia behavior will enable the
client family/caregiver to provide the client with a safe environment.

Refer family to social services or other supportive services to assist with meeting the
demands of caregiving for the client with dementia. Black caregivers of dementia clients
may evidence less desire than others to institutionalize their family members and are more
likely to report unmet service needs (Hinrichsen, Ramirez, 1992). Families of dementia
clients may report restricted social activity (Haley, 1995).

Encourage family to make use of support groups or other service programs. Studies
indicate that some minority families of clients with dementia may use few support
programs even though these programs could have a positive impact on caregiver well-
being (Cox, 1999).

Validate the family members feelings with regard to the impact of client behavior on
family lifestyle. Validation lets the client know that the nurse has heard and understands
what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger,
Davidhizer, 1995).

Home Care Interventions

NOTE: Keeping the client as independent as possible is important. However,

because community-based care is usually less structured than institutional care,
in the home setting, the goal of maintaining safety for the client takes on primary
importance.

Provide support to family of client with chronic and disabling condition.

If client will require extensive supervision on an ongoing basis, evaluate client for day
care programs. Refer family to medical social services to assist with this process if
necessary. Day care programs provide safe, structured care for the client and respite for
the family. Respite care for caregivers is an essential part of successful long-term care for
a confused client.
 Encourage family to include client in family activities when possible. Reinforce use of
therapeutic communication guidelines (see Client/Family Teaching) and sensitivity to the
number of people present. These steps help the client maintain dignity and lead to familiar
socialization of the client.

Assess family caregivers for caregiver burden. Caring for a loved one with a
dementing process is highly stressful. Respite care is a necessary component to the overall
care plan.

Client/Family Teaching

Recommend that the family develop a memory aid wallet or booklet for client that
contains pictures and text that chronicle the client's life. Using memory aids such as
wallets or booklets helps dementia clients make more factual statements and stay on
topic, and it decreases the number of confused, erroneous, and repetitive statements
(Bourgeois, 1992).

Teach family how to converse with a memory-impaired person. Guidelines include the
following:

o Ask client to have a conversation with you.

o Guide conversation to specific, nonthreatening topics and redirect the conversation

back on topic when client begins to ramble.

o Reassure and help out when the client gets stuck or cannot find the right words.

o Smile and act interested in what client is saying even if unsure what it means.

o Thank client for talking.

o Avoid quizzing client or asking a lot of specific questions.

o Avoid correcting or contradicting something that was stated even if it is wrong.

These guidelines can help family interact more effectively with client and decrease
frustration levels (Bouregois, 1992).

Teach family how to set up environment and use care techniques/interventions listed
so that client will experience a progressively lowered stress threshold. Alzheimer's clients
are unable to deal with stress; decreasing stress can decrease confusion and changes in
behavior (Hall, 1991; Stolley, 1994).

Discuss with the family what to expect as the dementia progresses.

Counsel the family about resources available with regard to end-of-life decisions and
legal concerns.

Inform family that as dementia progresses, hospice care may be available in the
terminal stages in the home to help the caregiver. Hospice services in the late stages of
dementia can help support the family with nursing services and visitation by primary care
provider, home health aides, social services, volunteer visitors, and a spiritual counselor if
desired as the client is dying (Boyd, Vernon, 1998).

NOTE: The nursing diagnoses Impaired Environmental interpretation syndrome

and Chronic Confusion are very similar in definition and interventions. Impaired
Environmental interpretation syndrome must be interpreted as a syndrome
where other nursing diagnoses would also apply. Chronic Confusion may be
interpreted as the human response to a situation or situations that require a level
of cognition no longer available to the individual. Further research is underway to
make this distinction clear to the practicing nurse.