Nursing School Survival Series – Acute Confusion

It starts out as a nice day at clinicals. Your nurse is happy to be working with you – bonus. You were prepared, organized and your morning is going nice and smooth. You go in to check on your previously alert and oriented patient…. and they are no longer very alert and no longer oriented. NOW WHAT? …although you will need to get your nurse and/ or instructor, what should you be thinking about in a patient with new onset of acute confusion? And in reality, one day you will be that nurse, so let’s learn what to do now!

Acute Confusion

Let’s recall a few things you do know.

The brain, like any organ likes

  • blood flow,
  • oxygen,
  • food
  • doesn’t like invaders.

Realize that most of this investigation will be done at the same time, so they are not necessarily in any order.

Nursing Care in a Patient with Acute Confusion

  • Rule out stroke

Always quickly think about catastrophic neurologic injury such as stroke. This is the time you get to really use all those intricate neurologic assessments. Look for asymmetry in the face and / or loss of muscle strength. (This is assuming you did an adequate FULL assessment of your patient first thing in the shift.) Remember, the brain needs blood flow and oxygen – if there is a clot or bleeding in the head, the brain can’t get either efficiently. This why you see the neurological deficits. So try to rule out a catastrophic neuro event quickly – time is tissue! If you think your patient is behaving a stroke, they need prompt attention.

  • Adequate oxygen

It may seem very obvious, but yes, your brain needs oxygen. Again, this is a quick assessment of not only their respiratory status, but the oxygen saturation. Again, it seems simple enough, but is often overlooked, especially if the patient doesn’t have a primary respiratory problem. Just a little bit of oxygen will go along way and can perk them right up.

  • Check the patient’s blood sugar

This is easy enough – do  a quick finger blood sugar test. Hypoglycemia is a common reason for altered mental status. As well as, pretty easy to fix. So rule it out quickly and / or intervene quickly. If the patient is diabetic, your concerns should be heightened. However, even if they are not diabetic, hypoglycemia should be considered. The opposite, hyperglycemia, is also a possibility, so rule it out with a quick capillary blood sugar.

  • Adequate blood flow

Hopefully by this point in time, as you are moving through your assessments, the vital signs have been obtained. The brain needs one of the lowest perfusion pressures, however, it does need perfusion. Hypotension is often the cause of changes in mental status due to the lack of perfusion pressure to the brain. Makes sense, if you can’t get the blood up there, the brain has nothing to work with. Hypotension needs to be addressed quickly, usually with fluid as the first action. So start to evaluate your patient’s intake & output – are they dehydrated, possibly causing or contributing? Either way, you should probably be anticipating the use of IV fluids to assist the situation.

  • Rule out “invaders”

Again, brain physiology is fragile and it doesn’t take much to disrupt this balancing act. One of the first things that should be on your radar, especially in the elderly population is infection, specifically urinary tract infections. They are particularly sensitive, even without having symptoms. But, don’t just think this is segregated to the elderly population, as patients of any age can develop metabolic encephalopathy, especially in overwhelming infection and sepsis. Although, not as common in the hospitalized patient, meningitis should be considered – both viral and bacterial.

Another “invader” to consider is medications, specifically narcotics. As the nurse, you should be aware of all the medications that have been administered, however, you also need to consider possible “home medications” that may have been ingested. A quick dose of a reversing agent will assist in identifying if this is your problem.

So, the next time you patient has a change in mental status, you should have a game plan of attack to quickly assist your patient.

Remember, the brain needs blood flow, oxygen, food and doesn’t like invaders.

I hope this has been helpful. I would love to hear your feedback, so please feel free to leave a comment.

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Take care, be safe and wash your hands!!!!

 

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