8 Important Nursing Assessments for the Patient with Confusion

The patient with confusion often presents a challenge for the nurse. Many are quick to dismiss the confusion, regarding the patient as “cute” or saying “they’re always confused,” or “they just have Alzheimer’s.” But beware! These types of reactions on the part of the staff may actually be signs of ageism or infantilizing and do not meet nursing professional standards of care. The licensed nurse is held to a higher standard of practice than this and is responsible to fully assess their confused patients in order to decide how to best handle their care.

Here are eight essential assessment parameters applicable to the patient with confusion:

1. Assess the patient’s history.

Is this confusion new? It is critical to learn the history of the patient. A state of confusion that has been present for weeks or months is very different from confusion that is new to the patient. The onset of new confusion, or delirium, is considered an emergency state until proven otherwise.

2. Assess the patient using the Confusion Assessment Method (CAM).

The Confusion Assessment Method is an evidence-based tool that helps identify the presence of delirium. Whether the CAM is positive or negative, you should continue through to the next steps of the assessment.

3. Assess vital signs, including pulse oximetry.

Compare new vital signs to those taken previously to see if they have changed. Look for an increased (or decreased) pulse and blood pressure, fever, or changes in oxygenation. Consider checking their blood sugar with a glucose meter.

4. Assess for signs of infection, such as pneumonia, Covid-19, UTI, or pressure ulcers.

Listen to chest sounds, inspect the urine and the skin, assess for productive cough, note characteristics of the sputum, and monitor for signs of Covid-19.

5. Assess for signs of myocardial infarction or another acute medical event.

Look for evidence of cardiac pain, abdominal pain, stroke, or even injury from a fall.

6. Assess neurological signs.

Evaluate the patient’s orientation, clarity of speech, balance, and strength.

7. Assess for other physical issues.

Screen for constipation, dehydration, pain, causative medications, and sleep disturbance.

8. Assess for safety issues. Is this patient at risk for falls, injury to self or others, or elopement?

A patient with new onset confusion should always be reported to the physician. Communicate your assessment to the physician, and expect orders for labs, x-rays, and/or medication depending upon the situation. Communicate your findings to other staff, and initiate a plan of care to address the patient’s unique issues.

Remember that a patient with well-known, long-term confusion can have delirium (acute onset confusion) as well as dementia at the same time. Do not dismiss the patient with a diagnosis of dementia, Alzheimer’s, or brain injury as simply being “confused as always.” Today their confusion may be different than the day or week prior, and it may be more dangerous. The nurse’s role is to look beyond the diagnosis of dementia and prevent an acute situation from worsening.

Finally, document, document, document! Documentation is not only required but also vital in helping caregivers on different shifts and other providers understand what has been happening with the patient over time. As nurses, we must prioritize providing a full assessment to the confused patient. We are among those who can prevent hospitalization—and even save a life.