May 20, 2018

Confused Patient Nursing Assessment


You walk into the room and notice your patient is restless and confused. During beside report, you were told the patient was alert and oriented and did not have fluctuations in mentation. You complete your assessment but are concerned regarding the mentation change, what do you do? Here is a quick breakdown of recommendations on how to approach situations involving confused patients.

#1. ASSESSMENT
Well first, let's make the patient's room as safe as we can. Can you hear your professor rambling the list in your head?

Bed is in the LOWEST position, side rails x two are UP, bed alarm is ON, call light is WITHIN reach, side table is PRESENT, room lights are ON, and non-skid socks are ON.

I know this sounds self-explanatory but you have no idea how many are flagged as confused (or require assistance) and yet, I walk into a room and NO safety measures are in place. Run down the list, chart the list has been initiated, and then you can go onto more important things. If a confused patient falls, the first question you will be asked is, "what safety measures were in place before the fall occurred?" Trust me, one minute of work will save you hours of charting and transports to XR/CT/MRI.

Now, let's get into it. We need to confirm our ABCs are in under control (airway, breathing, circulation), and perform focused neurological, respiratory, and cardiovascular physical assessments. Afterward, get yourself a set of full vital signs. The goal is to physically assess your patient before you start placing calls or notifying the rapid response team. You shouldn't be calling anyone or initiating any treatments until you ASSESS your patient. The assessment might look like this...

Neurologically: Patient agitated, eyes open spontaneously, best verbal response: confused, best motor response: obey commands, LOC alert, speech clear, L/R eye position midline, size 2mm, round, brisk, no facial droop or ptosis present. Gag and cough reflexes present. L/R limbs strength normal, purposeful. Denies trauma, HA, changes in eyesight, and N/V. Respiratory: Patient on BIPAP 5/5/65% (good seal), O2 is 100%, unlabored, symmetrical, diminished breath sounds. Denies SOB and dyspnea. Cardiovascular: Atrial fibrillation, controlled. Heart rate 80-90s, pulses palpable +2, capillary refill < 2. Denies chest pain and heart palpitations.

The physical examination could suggest congestive heart failure, pneumonia, or signs of illicit drug use. Fever indicates an infection as the cause of altered mental status and should prompt a search for the source, particularly urinary tract infection in the older patient. New focal neurologic findings suggest a possible mass lesion or stroke.

#2. BACKGROUND
After the full physical assessment is completed, get a detailed history. The primary goal of obtaining history is to determine when the patient last exhibited normal thinking and behavior and what normal is for the particular patient. History can be obtained from the chart, family members at the bedside, or nursing staff. Here is an example:

Patient 65 y/o male. Admitted 5/19 with shortness of breath. PMH: HTN, DM2, COPD, CAD, AICD, CHF, EF 20-25% (October 2017), CKD (stage 5) with HD MWF. Upon initial assessment (19:00), patient confused and agitated. Last reported oriented time is 17:00 per AM RN. No history of neurological, impairment, dysfunction, or deficits. New onset, the exact time of event initiation is unknown.

Providers can't create quality differential diagnoses and workups without adequate background information (current clinical picture, past medical history, diagnostics, and laboratory results). You must have the background information to paint the proper clinical presentation. Could this be ICU delirium? Did you perform a CAM-ICU delirium assessment? Is there a history of dementia? Does your patient have a history of stroke or cardiovascular dysfunction? The process is, "to assess your patient and then go research your patient." You are the patient's advocate. You can't truly advocate without knowing the full clinical picture and contributing factors. New-onset neurological changes mean nothing, without identifying background components. What looks like a change in mentation could be Parkinson's disease. You don't know what acute-onset signifies until you know your patient's history.

#3. DIFFERENTIALS
Common differential diagnoses for confusion include:

▪  Infection
▪  Hypoglycemia
▪  Failure to oxygenate
▪  Failure to ventilate
▪  Dementia/sundowning
▪  Cardiovascular injury or dysfunction
▪  Neurological injury or dysfunction
▪  Electrolyte and fluid disturbance
▪  Endocrine disease (thyroid, adrenal)
▪  AIDS-related complex
▪  Exogenous toxins
▪  Drug withdrawal
▪  Psychiatric origin

Your assessment/research will assist providers is pinpointing a diagnosis and appropriate workup.

#4. PLAN
Here are routine diagnostics/tests ordered for confused patients. This list isn't all-inclusive, just a list of common items.

▪  Blood cultures
▪  Urinalysis (UA)
▪  Chest x-ray (CXR)
▪  Hematology testing (CBC)
▪  Chemistry testing (CMP)
▪  Liver function testing (LFT)
▪  Thyroid function testing (TFT)
▪  12-lead electrocardiography (EKG)
▪  Cranial computed tomography (CT)
▪  Magnetic resonance imaging (MRI)
▪  Arterial blood gas (ABG)
▪  Lumbar puncture (LP)
▪  Toxicology testing

#5. GOALS
Confusion has many causes, and various tests can be ordered to find the culprit. As a nurse, make sure you perform quality physical assessments, obtain patient background information, and complete the ordered diagnostic and laboratory tasks. Your priorities are safety and care management. Don't let the signs and symptoms overwhelm you, take it one body system at a time. Confusion is a symptom, not a diagnosis. Getting to the diagnosis might take some time.