1. Confusion/disorientation
    1. Definition: loss of reality orientation as to person, time, place, events, ideas.
    2. Assessment: note unusual behavior:
      1. Picking, stroking movements in the air or on clothing and linens.
      2. Frequent crying or laughing.
      3. Alternating periods of confusion and lucidity (e.g., confused at night, when alone in the dark).
      4. Fluctuating mood, actions, rationality (argumentative, combative, withdrawn).
      5. Increasingly restless, fearful, leading to insomnia, nightmares.
      6. Acts bewildered; has trouble identifying familiar people.
      7. Preoccupied; irritable when interrupted.
      8. Unresponsive to questions; problem with concentration and setting realistic priorities.
      9. Sensitive to noise and light.
      10. Has unrealistic perception of time, place, and situation.
      11. Nurse no longer seen as supportive but as threatening.
    3. Analysis/nursing diagnosis: Altered thought processes and sensory/perceptual alterations related to:
      1. Physical and physiological disturbances - metabolic (uremia, diabetes, hepatic dysfunction), fluid and electrolyte imbalances, cardiac arrhythmias, heart failure; anemia, massive blood loss with low hemoglobin; brain lesions; nutritional deficiency; pain; sleep disturbance; drugs (antidepressants, tranquilizers, sedatives, antihypertensives, diuretics, alcohol, PCP, street drugs).
      2. Unfamiliar environment - unfamiliar routine and people; procedures that threaten body image; noisy equipment.
      3. Loss of sensory acuity from partial or incomplete reception of orienting stimuli or information.
      4. Disability in screening out irrelevant and excessive sensory input.
      5. Memory impairment.
    4. Nursing care plan/implementation:
      1. Check physical signs, e.g., vital signs, neuro y logical status, fluid and electrolyte balance, and blood urea nitrogen.
      2. Be calm; make contact to reorient to reality:
        1. Avoid startling if person is alone, in the dark, sedated.
        2. Make sure person can see, hear, and talk to you - turn off TV; turn on light, put on client’s glasses, hearing aids, dentures.
        3. Call by name, clearly and distinctly.
        4. Approach cautiously, close to eye level.
        5. Keep your hands visible; for example, on bed.
      3. Take care of immediate problem, e.g., disconnected IV tube or catheter.
        1. Give instructions slowly and distinctly; avoid threatening tone and comments.
        2. Stay with person until reoriented.
        3. Put side rails up.
      4. Use conversation to reduce confusion:
        1. Use simple, concrete phrases; language the person can understand; repeat as needed.
        2. Avoid: shouting, arguing, false promises, use of medical abbreviations (e.g., NPO).
        3. Give more time to concentrate on what you said.
        4. Focus on reality-oriented topics or objects in the environment.
      5. Prevent confusion by establishing a realityoriented relationship.
        1. Introduce self by name.
        2. Jointly establish routines to prevent confusion from unpredictable changes and variations. Determine client’s usual routine; attempt to incorporate this to lessen disruption in lifestyle.
        3. Explain what to expect in understandable words - where client is and why, what will happen, noises and activities client will hear and see, people client will meet, tests and procedures client will have.
        4. Find out what meaning hospitalization has to client; reduce anxiety related to feelings of apprehension and helplessness.
        5. Spend as much time as possible with client.
      6. Maintain orientation by providing nonthreatening environment.
        1. Assign to room near nurse’s station.
        2. Surround with familiar objects from home (e.g., photos).
        3. Provide clock, calendar, and radio.
        4. Have flexible visiting hours.
        5. Open curtain for natural light.
        6. Keep glasses, dentures, hearing aids nearby.
        7. Check client often, especially at night.
        8. Avoid using intercom to answer calls.
        9. Avoid low-pitched conversation.
      7. Take care of other needs.
        1. Promote sleep according to usual habits and patterns to prevent sleep deprivation.
        2. Avoid sedatives, which may lead to or increase confusion.
        3. Promote independent functions, self-help activities, to maintain dignity.
        4. Encourage nutritional adequacy; incorporate familiar foods, ethnic preferences.
        5. Maintain routine; avoid being late with meals, medication, or procedures.
        6. Have realistic expectations.
        7. Discover hidden fears.
          1. Do not assume confused behavior is unrelated to reality.
          2. Look for clues to meaning from client’s background, occupation.
        8. Provide support to family.
          1. Encourage expression of feelings; avoid being judgmental.
          2. Check what worked in previous situations.
      8. Health teaching: explain possible causes of confusion. Reassure that it is common. Teach family, friends how to react to confused behavior.
    5. Evaluation/outcome criteria:
      1. Less restlessness, fearfulness, mood lability.
      2. More frequent periods of lucidity; oriented to time, place, and person; responds to questions.