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Difficulty: MediumAging Process

An 85-year-old client residing in a long-term care facility suddenly exhibits severe agitation, disorientation, and disorganized thinking. The unlicensed assistive personnel reports that the client was completely alert, oriented, and calm earlier in the shift. In what order should the nurse perform the following assessment actions to evaluate this acute change? Arrange the steps from first (highest) priority to last (lowest) priority.

  1. 1Assess airway, breathing, circulation, and obtain vital signs including oxygen saturation.
  2. 2Perform a rapid neurological assessment to evaluate for focal deficits.
  3. 3Obtain a capillary blood glucose level and assess for signs of systemic infection.
  4. 4Review the medication administration record for newly prescribed drugs or recently administered PRN medications.
  5. 5Contact the client's family to confirm their precise baseline cognitive function.

Answer

The correct priority order is to first assess ABCs and vital signs, followed by a rapid neurological assessment, checking blood glucose and infection signs, reviewing the medication record, and finally contacting the family for baseline cognitive history.
The correct sequence follows the airway, breathing, circulation (ABC) prioritizing framework, moving from immediate life-threatening physiological needs to focused physical assessments, and finally to historical data collection. Acute confusion in an older adult is considered delirium until proven otherwise and requires urgent investigation for underlying hypoxia, stroke, infection, or medication toxicity.

Step-by-Step Solution

1
Assess airway, breathing, circulation, and vital signs including pulse oximetry.
Physiological stability is confirmed or immediate interventions are initiated.
Hypoxia or hemodynamic instability are critical, immediate life-threats that commonly present as acute confusion in older adults.
2
Perform a rapid neurological evaluation.
Focal neurological deficits (e.g., signs of a stroke) are ruled out or identified.
Acute cerebrovascular events require immediate, time-sensitive medical interventions and must be evaluated immediately after basic life support parameters.
3
Obtain capillary blood glucose and evaluate for signs of systemic infection (e.g., UTI, pneumonia).
Metabolic and infectious causes of delirium are identified.
Older adults often present with acute confusion as the primary or sole atypical symptom of an infection or metabolic imbalance.
4
Review the client's medication administration record (MAR).
Potential iatrogenic causes of confusion are identified.
Age-related physiological changes increase susceptibility to adverse drug events, making medication toxicity a frequent cause of acute mental status changes.
5
Interview family or caregivers to confirm baseline cognitive status.
The nurse establishes the exact symptom onset and differentiates acute delirium from chronic dementia.
Gathering collateral history provides essential context, but it is secondary to stabilizing and physically assessing the acutely changing client.

Key Concept

Prioritization of acute delirium assessment in the aging population
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Topics

Aging Process

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