Acute confusion care plan help?

[saffronclover]

Hello, everyone,

I'm a first semester nursing student and am getting stuck on a care plan for a neuro case study. Here's the data I'm working with:

Ms M was given Dilaudid 4 mg IV for the first time post-op for complaints of pain rated 9 on a scale of 0-10. Fifteen minutes later, the student nurse enters the room and finds Ms M on the floor. She is disoriented to time and place and cannot recall what happened. She made a few inappropriate responses to your questions and has some difficulty concentrating. She becomes irritable and frustrated with multiple commands. She does not have any obvious injuries as a result of the fall. The doctor orders blood work and her blood sugar is 157 and her sodium is 140.

The instructor assigned the nursing diagnosis of "acute confusion" but this confuses me a bit! NANDA only lists 6 etiologies for this dx: alcohol abuse, delirium, dementia, drug abuse, fluctuation in sleep-wake cycle, and over 60 years in age. We're using this patient in a larger case study throughout the semester and she is under 60. (She will turn out to be a diabetic, but I have to ignore that for now.) I've researched delirium and it sounds pretty severe (too severe for her symptoms??), but I don't have any "real world" experience to draw on about delirium. I have a care plan book (Gulanick/Myers) and they only tackle chronic confusion and disturbed thought processes, so that's not helping.

Since I have to do acute confusion, what would my R/T be? I guess my problem lies in not knowing what is causing her confusion. Delirium? Fluctuations in her sleep-wake cycle because of her surgery? Or can I use the client's hyperglycemia, receiving anesthesia for surgery, and/or the fact that she received Dilaudid as the basis for her confusion, since those things could mess with a person's alertness, even though NANDA doesn't list them? I feel like I'm missing some vital piece of this puzzle that would clarify everything. I guess it would help to know if all this qualifies for delirium.

I know once I get this figured out and set goals/outcomes, I'll be just fine thinking of interventions. I don't want to sound like someone who just wants the easy answer of what to write on their care plan--I truly want to do as much of this on my own and really understand what is going on with this patient. I just need a little nudge in that direction! Can anyone help me figure out what I'm missing here? Thanks in advance for any help you can give!

[pharmgirl]

Ok since Dilaudid seems to be the focus here, lets start with that. On the floor we usually give between 1-2mg of Dilauded the first time around. 4mg seems an awful lot, especially for a first time dose. She could possibly be experiencing an overdose of Dilaudid, which would cause confusion.

Just a thought.

[Daytonite, BSN, RN]

Are you saying that you have to stick strictly with the etiologies listed in the NANDA taxonomy? They are only suggestions. The woman is confused because of the drugs she has gotten. It is not drug abuse as the taxonomy would suggest, but her confusion is because of the delirium caused by the side effects off the Dilaudid. Acute Confusion R/T delirium secondary to Dilaudid ingestion AEB disoriented to time and place, inability to recall events, inappropriate responses to questions, difficulty concentrating and becoming irritable and frustrated with multiple commands.

[saffronclover]

Thanks, Pharmgirl and Daytonite. I wondered about the amount of Dilaudid myself when I looked up her meds but was unsure what a patient's reaction would be in the "real world". I was also unsure if I had to stick with the etiologies that NANDA lists, because my instructor hasn't gone into this yet, and something I read on another thread confused me there. Thanks again, you're both lifesavers!

[Daytonite, BSN, RN]

Part of your responsibility as a student and learner is to look up the definition of medical terms being used in these scenarios as well as the side effects of drugs being used. One of the things that I stress in most of my posts when helping students doing care planning and diagnosing is that a nursing problem, which is what a nursing diagnosis gets attached to, is the patient's response to what is happening to them whether it is as a result of their medical disease, medical treatment or just the stress of what is happening in their life. In this case, the patient's response to the drug is what is the cause of the nursing problems and there are more than one nursing problems here than the confusion as I am sure your instructor will point out as you work through this scenario. Best wishes to you.

[saffronclover]

Daytonite, why can't I have you as an instructor? :) You make it all so clear and then I think, "Now, why didn't I see that?" My instructor hasn't gone through any of this with us and I haven't gotten any constructive criticism from her on my previous care plans, so I feel a little lost and uncertain about everything (not feelings I like!).

I look all these things up and try to understand it all, but I'm still having trouble putting all the pieces together. I think I also get bogged down by the other nursing problems in the scenario. I'm hoping that will get easier with time and experience!

[Daytonite, BSN, RN]

Daytonite, why can't I have you as an instructor? :)

1. I'm an old lady
   
2. I am stuck at home and sick
   
3. I am as close as your computer
   

I have a lot of time to think about how it could be easier for you guys. I wrote care plans for years and struggled with them in earlier days so I know what you're going through. All you have to do is ask your questions and I will answer them as best as I can if I am feeling up to posting. I am on chemotherapy again and I have days where I just don't feel like sitting at the computer. I have so many previous posts on allnurses, however, that there really aren't many new questions that are asked. I suspect some instructors may not know how to explain how the NANDA taxonomy works themselves. Truth be told, most nurses, including instructors, hate having to do care plans.

[saffronclover]

Daytonite, I think you may be right about some instructors and NANDA taxonomy. Or even care plans themselves. Some instructors seem to want to throw everything including the kitchen sink into one care plan. One instructor even gives her students the R/T & AEB factors, which I feel isn't doing them any favors when they have to come up with care plans on real patients further down the road.

I'm having some problems coming up with proper interventions after all on this one. For example, do I address safety as an intervention? I assume in a hospital, this patient would be monitored closely to prevent further accidents. I also assume a nurse would monitor VS frequently for further complications from the Dilaudid administration. But would these interventions be more appropriate for a separate ND? Should I focus more on keeping the patient calm and minimizing her confusion? I'm trying to be thorough but also focused on the proper ND and not throwing in that kitchen sink.

Also, what sort of knowledge outcome is appropriate for a confused patient? I honestly can't think of what I can teach her--more what I can teach her family. I guess once she's reoriented, I can explain what happened to her and reassure her about it!

Thank you so much again for your help on this. I feel like such a dummy asking for help :) but it's very reassuring to receive input from a nurse with lots of experience. I'm sorry you're having to do chemotherapy again and fully understand if you don't feel up to responding to this. I hope your bad days are far outweighed by your good days. Take care!

[Daytonite, BSN, RN]

Just as a doctor treats symptoms, so do we. Taking the nursing diagnostic statement I used (Acute Confusion R/T delirium secondary to Dilaudid ingestion AEB disoriented to time and place, inability to recall events, inappropriate responses to questions, difficulty concentrating and becoming irritable and frustrated with multiple commands) and breaking it down, this patient's symptoms of the Acute Confusion are:

• disoriented to time and place
  
• inability to recall events
  
• inappropriate responses to questions
  
• difficulty concentrating
  
• becoming irritable and frustrated with multiple commands
  

So, the nursing interventions focus on these symptoms. What interventions can you do for someone who is disoriented to time and place?

• Goal: Patient will know the time and place
  
• Reorient to time and place as necessary
  
  • Rationale: Reduces confusion and anxiety and helps maintain reality.
    

  [*]Always face the patient when talking with them

  • Rationale: Maintaining eye contact conveys interest, arouses the patient's attention and helps to maintain reality.
    

  [*]Always address the patient by their name

  • Rationale: Along with establishing reality this helps the patient to maintain their identity.
    

For becoming irritable and frustrated with multiple commands. . .

• Goal: Decrease in irritability and frustration
  
• Be pleasant and approach in a slow, calm manner
  
  • Rationale: Helps to reduce distortion of the input the patient does receive and lessens the chance of them misinterpreting what they hear. A hurried approach threatens and scares some confused patients.
    

  [*]Speak slowly and distinctly and with a low voice

  • Rationale: Increases the patient's understanding and the low voice tones are less likely to provoke an angry response
    

  [*]Give simple directions, preferably step-by-step instructions using short words

  • Rationale: Simple instructions are easier for a confused person to process and understand.
    

  [*]Pause between sentences

  • Rationale: Allows the patient to respond by action or ask for clarification.
    

  [*]Do not force the patient to do any activity or respond to any questions

  • Rationale: Discourages cooperation and can increase anger and frustration
    

  [*]Monitor for the side effects of medications that may be causing this behavior

  • Rationale: Build up of some drugs can lead to confusion and dosages may need to be corrected.
    

I am a little confused as to what you are actually care planning. Are you to come up with several diagnoses or work on the diagnosis that the instructor gave you? I recognize that Acute Confusion isn't the only nursing problem here, but I assumed that it is the one you are to focus on. Risk for Falls and Acute Pain would be other ones, but since you didn't mention anything about them, I didn't focus on them. You are also bringing safety and teaching issues into this and I am not understanding why.

[saffronclover]

I am a little confused as to what you are actually care planning. Are you to come up with several diagnoses or work on the diagnosis that the instructor gave you? I recognize that Acute Confusion isn't the only nursing problem here, but I assumed that it is the one you are to focus on. Risk for Falls and Acute Pain would be other ones, but since you didn't mention anything about them, I didn't focus on them.

I just have to work on the diagnosis of acute confusion that the instructor gave me. My initial interventions were aimed at addressing the delirium, but it seemed like my classmates were including safety and pain management. I feel these merit their own NDs, but since I'm new to this, I'm incredibly paranoid about leaving out an important intervention. I was afraid that if I concentrated solely on keeping the patient calm and getting her reoriented, my instructor would say, "What about safety?" or "What about pain management?"

The reason I brought up teaching is that we have to set knowledge goals in addition to our regular goals and outcomes. They have to address how the patient's knowledge changes or methods the patient will use to accomplish the knowledge goal after the nurse teaches it. I personally have no idea what one teaches a patient who is in the throes of delirium without making the situation worse!

I think I just panicked because I felt overwhelmed and uncertain. I feel like I've regained my focus again after hearing your feedback. You're a star! Thanks so much!

[Daytonite, BSN, RN]

got it. first of all, don't be too concerned with what the other students are doing. they may not be doing the right thing. concentrate on what you were instructed to do which is work on the diagnosis of acute confusion.

when care planning you are using the nursing process to help with the problem solving. your scenario gave you the symptoms (i listed them out in the nursing diagnostic statement) and that covers step #1 (assessment). determination of the nursing problem, step #2 of the nursing process, was done for you as well--acute confusion. step #3 of the nursing process (this care planning procedure) is to set goals/outcomes and order nursing interventions. they are based on the symptoms the patient has for this diagnosis of acute confusion. i wrote two very simple goals and some interventions for two of the symptoms and left the other 3 for you to work on yourself. what i wanted you to see is that the interventions are directly related to treating the symptoms and that the goals reflect what would happen if the interventions are successful. you may want to look up delirium and see what intervention can be done for it as well since it is permissible to address and treat the related factors. the problem with the dilaudid is that it is dependent on what the doctor has ordered so other than monitoring the patient for side effects and notifying the physician of what is going on with it in regard to causing confusion (stick with the problem here which is confusion) it depends on a doctor's order which makes any orders connected with it collaborative nursing actions. but you can include goals and interventions with relation to the delirium.

as for safety and teaching you may have to go a stretch for these, but keeping a patient from getting angry and blowing up, i think, is a safety issue. the definition of safety includes reducing danger or harm. the definition of learn is to instruct and i gave you at least one intervention that had to do with instruction. it doesn't mean that the patient, if tested, would pass a test that they learned what they were instructed on. goals can have 3 outcomes:

• improvement of the patient's condition/remedy
  
• stabilization of the patient's condition
  
• support for the deterioration of the patient's condition
  

we would all like our interventions to result in improvement of the patient's condition, in this case their confusion. however, in reality that doesn't always happen and sometimes the best we get, even with any teaching and instruction, is the same static condition or at times the patient even deteriorates because of their disease. so, subtle as they may seem there are safety and teaching interventions that are part of this care plan for acute confusion.

another thing is that nursing interventions are of 4 types:

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
• care/perform/provide/assist (performing actual patient care)
  
• teach/educate/instruct/supervise (educating patient or caregiver)
  
• manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
  

it is important, however, that everything you plan relates to acute confusion, not falling, not pain. those will be handled when those diagnoses are care planned. if you don't have a care plan book check the index of your nursing texts for subjects like poor recall, confusion, poor concentration, delirium, and difficulty concentrating and see what you can find there to help you with the interventions for the other symptoms.

making sense?

[saffronclover]

Making sense?

Yes, finally! Thanks! It really helps to reason it though with someone (and not other students who are as lost as I am!). I can't say I'll never have a care plan question again but the process is starting to make a lot more sense. I know your suggestions will help keep me on track when writing future care plans.