Alert but confused

[mytoon38]

I recently charted that a patient was alert, but confused and oriented x 1 to name only. I was told by one of the big wig nurse educators at our hospital that a pt. couldn't be ALERT and CONFUSED, and disoriented, she said that is a contradiction. I have been a nurse for over 25 years, and I was taught that: Alertness is a global observation of level of consciousness, awareness of, and responsiveness to the environment, and this might be described as alert, clouded or drowsy. So to me, as long as a pt isn't comatose and is responding to stimuli, they are alert! I would like to hear your opinion. Do you think a pt. can be alert but confused and disoriented????

Thanks!

[KelRN215, BSN, RN]

JessiG said:

I am a student and am attempting to write my final care plan for this semester. However, I am not sure what/how to write the alert and oriented statement. My patient is in her 90's and has dementia (unspecified), but seems to have more short-term memory loss than dementia related problems. She forgets who you are after an hour or so, asked my name about 5 times in 4 hours (and had to read my badge to understand my name), asked me when I was graduating about 4 times in 20 minutes...Yet, she knew who her normal CNA was (not sure of name but responded to and talked to her as if she was used to her care) and she spoke of her children who are still alive and one that passed away. Then she would have periods where she thought she was being punished when she had done nothing wrong, she would regress back to times of slavery (client is an African American female and lived through this time period) or complain that her meals were not the same size as the other residents... I am not sure how to write the A&O statement as the client seemed alert when speaking with her and she knew where she was, who she was, and most of what was going on around her, just not all of it...she was confused. Also, how does alert and oriented work if they forget the information in 10-20 minutes? At the time they know what is going on. Any advice?

Your patient is 150+ years old? Slavery in the United States was abolished in 1863.

[akulahawkRN, ADN, RN, EMT-P]

When I'm charting "alert" it's almost always charted as "awake and alert to changes in the environment" and I'll chart orientation separately as "and oriented x4" or I'll break out the components checked if not x4. If there's episodes of confusion, I'll note that as well with a description of the confused state. I suppose you could say that I use "alert" to describe responsiveness on the AVPU scale and "orientation" to indicate cognition. If I want/need to get a little more in-depth about cognitive ability, I might do serial 7's or spell world backwards as well, and note the result.

If they're not "awake" then I'll describe their arousability in terms of lethargic, somnolent, obtunded, stuporous, comatose.

[Meriwhen, ASN, BSN, MSN, RN]

mytoon38 said:

Do you think a pt. can be alert but confused and disoriented????

Actually, that describes a lot of my patients.

[morte, LPN, LVN]

akulahawk said:

If they're not "awake" then I'll describe their arousability in terms of lethargic, somnolent, obtunded, stuporous, comatose.

I think you may want to drop the "a" off the front of that word.

[microkate]

I use alert much as you do. To me alert is when they are awake and engaged with the environment and other people, regardless of the level of orientation.

I used to be a vet tech, and our equivalent of alert & orientedx4 was "BAR" - Bright, alert, and responsive.

[Niki_RN]

I'm a neuro nurse and for me a patient can be both alert and confused at the same time. Orientation and alertness are two separate things. The patient may be oriented but is lethargic or obtunded,etc and needs more stimuli to elicit a response. A patient may also be alert (meaning able to respond with minimal stimulation) but is confused (unable to identify correct time, place, situation, person).

You might want to clarify with her what she means by "alert" and "oriented". And further ask her examples: "So if the patient is responsive to verbal and visual stimuli but doesn't know time and place, what do you call that"?

[HeartRN13]

I agree with many of the replies here. Alert is a state of awareness, and when someone is alert they are functioning and awake. When you are alert you notice things, can be spoken to or speak to someone. Alert is also the opposite state of sedated or comatose. Someone who is sedated or comatose, even lethargic is not in a state of awareness or comprehension. Their mental state is altered so that they are possibly unable to process information correctly, or in a normal time period, or remember information.

Disorientation has to do with a patients perception of their environment and situation. Most of us know our name, know where we are, and can recognize our family members or even familiar staff members. Being able to identify all of these things accurately indicates orientation to settings. When someone is disoriented, they are having trouble remembering or recognizing. For whatever reason, medication effects, a dementia patient, someone just waking up from surgery; these are all things that can cause a person to become disoriented.

If a patient is disoriented but conversing and responding appropriately, to words and stimuli, then they are alert but disoriented.