Confusion
Alarm level explanation: The customer shows signs of confusion. The cause should be determined quickly. Make sure that the observation is correct and that the symptom is different from earlier. Consult a nurse or doctor. Some of the findings are due to lack of data and irregular recording of cognition in a customer with memory impairment. If the finding is new,
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Check the client’s vital signs. Body temperature should be 35-38C, pulse 60-100, respiratory rate 16-25/min and blood pressure below 160/95. Abnormalities in vitals may indicate infection.
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Dehydration Assess whether dehydration may be the cause of the confusion.
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Pain and pain medication Setting of pain medication according to need.
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Chronic Illnesses Some chronic illnesses may be associated with confusion. Act based on what has caused the confusion. E.g. low blood sugar in diabetics, etc.
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Medication Is the client using medication that can cause confusion? Have there been deviations in the administration of medicines?
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Environmental factors Is the customer using his hearing aids / glasses? Has the client recently been discharged from the hospital? Have the nurses changed often?
Warning level explanation: The customer may be showing signs of confusion. Make sure that the observation is correct and that the symptom is different from earlier. Consult a nurse or doctor . Some of the findings are due to lack of data and irregular recording of cognition in a customer with memory impairment. If the finding is new,
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Check the client’s vital signs. Body temperature should be 35-38C, pulse 60-100, respiratory rate 16-25/min and blood pressure below 160/95. Abnormalities in vitals may indicate infection.
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Dehydration Assess whether dehydration may be the cause of the confusion.
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Pain and pain medication Setting of pain medication according to need.
-
Chronic Illnesses Some chronic illnesses may be associated with confusion. Act based on what has caused the confusion. E.g. low blood sugar in diabetics, etc.
-
Medication Is the client using medication that can cause confusion? Have there been deviations in the administration of medicines?
-
Environmental factors Is the customer using his hearing aids / glasses? Has the client recently been discharged from the hospital? Have the nurses changed often?
Ok level explanation: The customer has no signs of confusion or there is no data available about it.