Recognising New Confusion for Student Nurses
Learn how to recognise an acute change in mental state, compare the patient with their usual baseline and understand why new confusion can be an important sign of illness or deterioration.
What might new confusion look like?
Acute confusion can present in different ways. Some patients become restless and agitated, while others become unusually quiet, sleepy or withdrawn. The important question is whether the patient's mental state has changed from their usual baseline.
Disorientation
The patient may suddenly appear unsure where they are, what is happening or what time or day it is.
Agitation or withdrawal
Restlessness, agitation, unusual quietness or reduced interaction may all represent a change.
Difficulty concentrating
The patient may struggle to follow conversation, maintain attention or respond consistently.
What should you assess?
Establish baseline
Find out whether the behaviour or mental state is new. Previous documentation, staff and relatives may help establish baseline.
Assess responsiveness
Observe alertness and use the consciousness assessment approach required in your clinical area.
Check observations
Review respiratory rate, oxygen saturation, pulse, blood pressure and temperature.
Consider oxygenation
New confusion alongside respiratory deterioration or altered oxygenation requires prompt assessment.
Consider glucose
Follow local policy and supervision regarding blood glucose assessment when clinically appropriate.
Look for wider clues
Consider pain, infection, dehydration, medication, elimination problems and other changes in the patient's condition.
Ask people who know the patient
A relative, carer or member of staff may recognise a subtle change immediately: “He is normally completely orientated” can be highly valuable information.
Possible causes of acute confusion
| Possible context | Other clues | What to think about |
|---|---|---|
| Infection | Temperature change, tachycardia, altered respiration or general deterioration. | Acute confusion can accompany significant infection, particularly in vulnerable patients. |
| Reduced oxygenation | Breathlessness, low oxygen saturation or increased oxygen requirement. | Altered mental state may accompany worsening respiratory function. |
| Dehydration | Poor intake, fluid loss, reduced urine output or hypotension. | Fluid depletion can contribute to acute deterioration and confusion. |
| Medication | Recent medication changes or medicines affecting alertness. | Medication may contribute, but new confusion still requires appropriate assessment. |
| Glucose disturbance | Altered behaviour, sweating, weakness or reduced consciousness. | Blood glucose abnormalities can alter mental state and require prompt recognition. |
| Pain or discomfort | Restlessness, guarding, distress or behavioural change. | Patients who struggle to communicate may express discomfort through behaviour. |
Confusion may be the presenting sign
A deteriorating patient does not always complain of a clear symptom. Sometimes a change in behaviour, attention or alertness is the first sign that something has changed.
Acute confusion can fluctuate
Delirium is an acute disturbance in attention and cognition that can fluctuate during the day. Patients may alternate between periods of greater clarity and periods of obvious confusion.
Restless or agitated
The patient may attempt to get out of bed, pull at equipment, call out or appear frightened.
Quiet or withdrawn
The patient may become unusually sleepy, less interactive or difficult to engage.
Changes through the day
Mental state may improve and worsen, making comparison with baseline and repeated assessment important.
When new confusion becomes particularly concerning
- There is a sudden change from the patient's normal mental state.
- The patient is becoming less responsive or increasingly drowsy.
- Respiratory rate or oxygen saturation is deteriorating.
- Blood pressure is falling or peripheral perfusion is poor.
- There are signs of infection or sepsis.
- There has been a fall, head injury or other acute event.
- The patient has new neurological signs.
- Blood glucose abnormality is suspected or identified.
- Several physiological observations are worsening together.
Putting the observations together
Example
You cared for a patient earlier in the shift who was alert, orientated and chatting normally.
Several hours later they appear restless and repeatedly ask where they are.
Their respiratory rate has increased, temperature is elevated and pulse is now significantly faster than earlier.
The key finding is not simply that the patient seems confused. It is the new change in mental state combined with worsening physiological observations.
As a student nurse, recognise the change, obtain appropriate observations and communicate your concerns promptly to the registered practitioner caring for the patient.
New confusion assessment errors to avoid
- Assuming confusion is normal because the patient is older. Establish their usual baseline.
- Assuming dementia explains a new change. A patient with dementia can also become acutely unwell.
- Focusing only on agitation. New sleepiness or withdrawal can also be important.
- Ignoring physiological observations. Mental-state change may accompany wider deterioration.
- Failing to ask relatives or carers. They may identify a change from normal immediately.
- Waiting for confusion to become severe. A new change deserves early assessment.
Recognise → assess → communicate → escalate
Notice the change
Identify new confusion, altered behaviour, reduced attention or unexpected drowsiness.
Look for a cause
Review observations, consciousness, oxygenation, glucose where appropriate, hydration and the wider clinical picture.
Explain what changed
Describe the patient's normal baseline, the new behaviour and any associated physiological changes.
Recognising Reduced Urine Output for Student Nurses
Learn how to recognise reduced urine output, review fluid balance and understand why falling urine output can provide an important clue to hydration, renal function and patient deterioration.
Continue to Reduced Urine Output →