7 Older adult care
Nursing diagnosis:
Acute confusion
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s baseline level of consciousness (LOC) and mental status on admission. Obtain preconfusion functional and mental status abilities from significant other. Ask patient to perform a three-step task. For example, “Raise your right hand, place it on your left shoulder, and then place the right hand by your right side.” | A component of the Mini-Mental Status Examination, this assessment of a three-step task provides a baseline for subsequent assessments of patient’s confusion. A three-step task is complex and is a gross indicator of brain function. Because it requires attention, it can also test for delirium. |
| Test short-term memory by showing patient how to use call light, having patient return the demonstration, and then waiting at least 5 min before having patient demonstrate use of call light again. Document patient’s actions in behavioral terms. Describe the “confused” behavior. | Inability to remember beyond 5 min indicates poor short-term memory. |
| Identify cause of acute confusion. | Acute confusion is caused by physical and psychosocial conditions and not by age alone. For example, oximetry or arterial blood gas (ABG) values may reveal low oxygenation levels, serum glucose or fingerstick glucose may reveal high or low glucose level, and electrolytes and complete blood count (CBC) will ascertain imbalances and/or presence of elevated white blood cell (WBC) count as a determinant of infection. Hydration status may be determined by pinching skin over sternum or forehead for turgor (tenting occurs with fluid volume deficit) and checking for dry mucous membranes and furrowed tongue. |
| Assess for pain using a rating scale of 0-10. If patient is unable to use a scale, assess for behavioral cues such as grimacing, clenched fists, frowning, and hitting. Ask family or significant other to assist in identifying pain behaviors. | Acute confusion can be a sign of pain. |
| Treat patient for pain, as indicated, and monitor behaviors. | If pain is the cause of the confusion, patient’s behavior should change accordingly. |
| Review cardiac status. Assess apical pulse and notify health care provider of an irregular pulse that is new to the patient. If patient is on a cardiac monitor or telemetry, watch for dysrhythmias; notify health care provider accordingly. | Dysrhythmias and other cardiac dysfunctions may result in decreased oxygenation, which can lead to confusion. |
| Review current medications, including over-the-counter (OTC) drugs, with pharmacist. | Toxic levels of certain medications, such as digoxin or theophylline, cause acute confusion. Drugs that are anticholinergic also can cause confusion, as can drug interactions. |
| Monitor intake and output (I&O) at least q8h. | Optimally, output should match intake. Dehydration can result in acute confusion. |
| Review patient’s creatinine clearance test to assess renal function. | Renal function plays an important role in fluid balance and is the main mechanism of drug clearance. Blood urea nitrogen (BUN) and serum creatinine are affected by hydration status and in older patients reveal only part of the picture. Therefore, to fully understand and assess renal function in older patients, creatinine clearance must be tested. |
| Have patient wear glasses and hearing aid, or keep them close to the bedside and within easy reach for patient use. | Glasses and hearing aids are likely to help decrease sensory confusion. |
| Keep patient’s urinal and other routinely used items within easy reach for patient. | A confused patient may wait until it is too late to seek assistance with toileting. |
| If patient has short-term memory problems, toilet or offer urinal or bedpan q2h while awake and q4h during the night. Establish a toileting schedule and post it on patient care plan and, inconspicuously, at the bedside. | A patient with a short-term memory problem cannot be expected to use the call light. |
| Check on patient at least q30min and every time you pass the room. Place patient close to nurses’ station if possible. Provide an environment that is nonstimulating and safe. | A confused patient requires extra safety precautions. |
| Provide music but not TV. | Patients who are confused regarding place and time often think the action on TV is happening in the room. |
| Attempt to reorient patient to surroundings as needed. Keep a clock with large numerals and a large print calendar at the bedside; verbally remind patient of date and day as needed. | Reorientation may decrease confusion. |
| Tell patient in simple terms what is occurring. For example, “It’s time to eat breakfast,” “This medicine is for your heart,” “I’m going to help you get out of bed.” | Sentences that are more complex may not be understood. |
| Encourage patient’s significant other to bring items familiar to patient, including blanket, bedspread, pictures of family and pets. | Familiar items may promote orientation while also providing comfort. |
| If patient becomes belligerent, angry, or argumentative while you are attempting to reorient, stop this approach. Do not argue with patient or patient’s interpretation of the environment. State, “I can understand why you may [hear, think, see] that.” | This approach prevents escalation of anger in a confused person. |
| If patient displays hostile behavior or misperceives your role (e.g., nurse becomes thief, jailer), leave the room. Return in 15 min. Introduce yourself to patient as though you had never met. Begin dialogue anew. | Patients who are acutely confused have poor short-term memory and may not remember the previous encounter or that you were involved in that encounter. |
| If patient attempts to leave the hospital, walk with patient and attempt distraction. Ask patient to tell you about the destination For example, “That sounds like a wonderful place! Tell me about it.” Keep tone pleasant and conversational. Continue walking with patient away from exits and doors around the unit. After a few minutes, attempt to guide patient back to the room. Offer refreshments and a rest. For example, “We’ve been walking for a while and I’m a little tired. Why don’t we sit and have some juice while we talk?” | Distraction is an effective means of reversing a behavior in the patient who is confused. |
| If patient has a permanent or severe cognitive impairment, check on her or him at least q30min and reorient to baseline mental status as indicated; however, do not argue with patient about his or her perception of reality. | |
| If patient tries to climb out of bed, offer urinal or bedpan or assist to the commode. | Patient may need to use the toilet. |
| Alternatively, if patient is not on bedrest, place him or her in chair or wheelchair at nurses’ station. | This action provides added supervision to promote patient’s safety while also promoting stimulation and preventing isolation. |
| Bargain with patient. Try to establish an agreement to stay for a defined period, such as until health care provider, meal, or significant other arrives. | This is a delaying strategy to defuse anger. Because of poor memory and attention span, patient may forget he or she wanted to leave. |
| Have patient’s significant other talk with patient by phone or come in and sit with patient if patient’s behavior requires checking more often than q30min. | These actions by significant other may help promote patient’s safety. |
| If patient is attempting to pull out tubes, hide them (e.g., under blankets). Put a stockinette mesh dressing over intravenous (IV) lines. Tape feeding tubes to side of patient’s face using paper tape, and drape the tube behind patient’s ear. | Remember: Out of sight, out of mind. |
| Evaluate continued need for certain therapies. | Such therapies may become irritating stimuli. For example, if patient is now drinking, discontinue IV line; if patient is eating, discontinue feeding tube; if patient has an indwelling urethral catheter, discontinue catheter and begin toileting routine. |
| Use restraints with caution and according to agency policy. | Patients can become more agitated when wrist and arm restraints are used. |
| Use medications cautiously for controlling behavior. | Follow the maxim “start low and go slow” with medications because older patients can respond to small amounts of drugs. Neuroleptics, such as haloperidol, can be used successfully in calming patients with dementia or psychiatric illness (contraindicated for individuals with parkinsonism). However, if patient is experiencing acute confusion or delirium, short-acting benzodiazepines (e.g., lorazepam) are more effective in reducing anxiety and fear. Anxiety or fear usually triggers destructive or dangerous behaviors in acutely confused older patients. |
| Also see “Dementia—Alzheimer’s Type,” p. 689, as appropriate. |
Nursing diagnosis:
Impaired gas exchange (or risk for same)
related to decreased oxygenation occurring with decreased functional lung tissue
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess and document the following upon admission and routinely thereafter: respiratory rate (RR), pattern, and depth; breath sounds; cough; sputum; and sensorium. | This assessment establishes a baseline for subsequent assessments of patient’s respiratory system. |
| Assess patient for subtle changes in mentation such as increased restlessness, anxiety, disorientation, and presence of hostility. If available, monitor oxygenation status via ABG findings (optimally Pao2 80%-95% or greater) or pulse oximetry (optimally greater than 92%). | Mentation changes such as increased restlessness, anxiety, disorientation, and presence of hostility can signal decreased oxygenation. |
| Assess lungs for presence of adventitious sounds. | The aging lung has decreased elasticity. The lower part of the lung is no longer adequately aerated. As a result, crackles commonly are heard in individuals 75 years of age and older. This sign alone does not mean that a pathologic condition is present. Crackles (rales) that do not clear with coughing in an individual with no other clinical signs (e.g., fever, increasing anxiety, changes in mental status, increasing respiratory depth) are considered benign. |
| Encourage patient to cough and breathe deeply. When appropriate, instruct patient in use of incentive spirometry. | These actions promote alveolar expansion and clear the secretions from the bronchial tree, thereby helping ensure better gas exchange. |
| Unless contraindicated by a cardiac or renal condition, encourage fluid intake to greater than 2.5 L/day. | Hydration helps ensure less viscous pulmonary secretions, which are more easily mobilized. |
| Treat fevers promptly, decrease pain, minimize pacing activity, and lessen anxiety. | These interventions reduce potential for increased oxygen consumption. |
| Instruct patient in use of support equipment such as oxygen masks or cannulas. | Knowledge helps promote adherence to therapy. |
Nursing diagnosis:
Risk for aspiration
related to depressed cough and gag reflexes or ineffective esophageal sphincter
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Perform a baseline assessment of patient’s ability to swallow by asking if he or she has any difficulty swallowing or if any foods or fluids are difficult to swallow or cause gagging. If patient is unable to answer, consult patient’s caregiver or significant other. Document findings. | This assessment helps determine patient’s ability to swallow without choking and should be compared with subsequent assessments to document improvements or deficits. |
| Assess patient’s ability to swallow by placing thumb and index finger on both sides of the laryngeal prominence and asking patient to swallow. Check for the gag reflex by gently touching one side and then the other of the posterior pharyngeal wall using a tongue blade. Document both findings. | Ability to swallow and an intact gag reflex are necessary to prevent aspiration and choking before patient takes foods or fluids orally. |
| Place patient in an upright position with chin tilting down slightly while eating or drinking, and support upright position with pillows on patient’s sides. | This position minimizes risk of choking and aspirating by closing off the airway and facilitating gravitational flow of foods and fluids into the stomach and through the pylorus. |
| Monitor patient when he or she is swallowing. | This assessment will help determine patient’s ability to swallow without choking. Deficits may necessitate aspiration precautions. |
| Watch for drooling of saliva or food, or inability to close lips around a straw. | These are signs of limited lip, tongue, or jaw movement. |
| Check for retention of food in sides of mouth. | This is an indication of poor tongue movement. |
| Monitor intake of food. Document consistencies and amounts of food patient eats, where patient places food in the mouth, how patient manipulates or chews before swallowing, and length of time before patient swallows the food bolus. | Other caregivers will find this information useful during subsequent feedings. |
| Monitor patient for coughing or choking before, during, or after swallowing. | Coughing or choking may occur up to several minutes following placement of food or fluid in the mouth and signals aspiration of material into the airway. |
| Monitor patient for changes in lung auscultation (e.g., crackles [rales], wheezes, rhonchi), shortness of breath, dyspnea, decreasing LOC, increasing temperature, and cyanosis. | These are signs of silent aspiration. For example, some older patients, especially those in declining health, have increased risk for silent aspiration when the esophageal sphincter fails to close completely between swallows. |
| Monitor patient for a wet or gurgling sound when talking after a swallow. | This sound indicates aspiration into the airway and signals delayed or absent swallow and gag reflexes. |
| For patients with poor swallowing reflex, tilt their head forward 45 degrees during swallowing. Note: For patients with hemiplegia, tilt head toward unaffected side. | This head position will help prevent inadvertent aspiration by closing off the airway. |
| As indicated, request evaluation by speech therapist. | This evaluation will enable specialized assessment of gag and swallow reflexes. |
| Anticipate swallowing video fluoroscopy in evaluation of patient’s gag and swallow reflexes. | This procedure is used to determine whether patient is aspirating, consistency of materials most likely to be aspirated, and aspiration cause. Using four consistencies of barium, the radiologist and speech therapist watch for the presence of reduced or ineffective tongue function, reduced peristalsis in the pharynx, delayed or absent swallow reflex, and poor or limited ability to close the epiglottis that protects the airway. |
| Based on results of the swallowing video fluoroscopy, thickened fluids may be prescribed. | Agents are added to the fluid to make it more viscous and easier for patient to swallow. Similarly, mechanical soft, pureed, or liquid diets may be prescribed to enable patient to ingest food with less potential for aspiration. |
| Provide adequate rest periods before meals. | Fatigue increases risk for aspiration. |
| Remind patients with dementia to chew and swallow with each bite. Check for retained food in sides of mouth. | Patients with dementia might forget to chew and swallow. |
| Ensure that patient has dentures in place, if appropriate, and that they fit correctly. | Chewing well minimizes risk of choking. |
| Ensure that someone stays with patient during meals or fluid intake. | This ensures added safety in the event of choking or aspiration. |
| Provide adequate time for patient to eat and drink. | Generally, patients with swallowing deficits require twice as much time for eating and drinking as those whose swallowing is adequate. |
| Be aware of location of suction equipment to be used in the event of aspiration. | If patient is at increased risk for aspiration, suction equipment should be available at the bedside. |
| If patient aspirates, implement the following: | |
– Follow American Heart Association (AHA) standards if patient displays characteristics of complete airway obstruction (i.e., choking). < div class='tao-gold-member'>
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