Family Center Nursing for An Acute Confusion in Diabetes Mellitus Elderly with COVID-19

Family Center Nursing for An Acute Confusion in Diabetes Mellitus Elderly with COVID-19 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Family Center Nursing for An Acute Confusion in Diabetes Mellitus Elderly with COVID-19 Ummi Malikal Balqis, Anggrayeni Purba, Kadek Novi Andani, Sinta Wijayanti, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7738924/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract COVID 19 is an infectious disease caused by the SARS-CoV-2 virus. Neurologically, COVID-19 in the elderly with diabetes mellitus presents with headaches, dizziness, acute confusion, unorganized thinking, and incoherence. The research aims of this study are to describe a comprehensive family center nursing for families with acute confusion in diabetes mellitus elderly covid 19. The Method of this study uses a case report design in 1 case diabetes mellitus elderly covid 19 who live with family during self-quarantine of covid 19. Observation and analysis of the case report based on NANDA-NOC-NIC International that was carried out through a telenursing approach. The results study shows that family center nursing for acute confusion in diabetes mellitus elderly with covid 19 who received nursing intervention including delirium management, vital sign monitoring, sleep enhancement, and medication management experienced a decrease in agitation level, blood glucose level, and delirium level from the elderly. This study is expected to be a reference for related institutions to develop family center nursing for families with elderly COVID-19 problems Acute Confusion Covid 19 Diabetes Mellitus Elderly Family Center Nursing INTRODUCTION Coronavirus disease (Covid-19) is the highly contagious infectious disease caused by the SARS-CoV-2 virus which causes COVID-19 patients to experience mild to moderate respiratory illness which caused more than 6 million deaths worldwide, emerging as the most consequential global health crisis since the era of the influenza pandemic of 1918 (Cascella et al., 2022 ; WHO, 2022 ). Along with comorbid diseases, COVID-19 is a disease with a high risk for those who are infected. Risk factors such as comorbidity, older age, lower lymphocyte count, and higher lactate dehydrogenase at presentation were independent high-risk factors for COVID-19 progression (Ji et al., 2020 ). From this explanation, the condition of the elderly causes the elderly with COVID-19 to become one of the groups with the highest morbidity and mortality. In Indonesia, 56% of deaths due to COVID-19 in January-March 2022 occurred in the elderly (Adisasmito, 2022 ). The high rate of mortality and morbidity in the elderly covid 19 cases makes covid 19 a scourge for the elderly. Elderly and those with underlying medical conditions such as diabetes mellitus are more likely to develop serious illnesses. COVID-19 patients with DM are 14–32% more at risk of experiencing severe or critical illness (Singh et al., 2020 ). High blood sugar was found to reduce immunity and increase the replication of SARS- CoV-2 while interacting with various other risk factors (Sen et al., 2021 ). The pathogenesis of COVID-19 and diabetes mellitus includes effects on glucose homeostasis, inflammation, changes in immune status, and activation of the renin-angiotensin-aldosterone system (RAAS) (Lim et al., 2021 ). This condition is the basis that more serious treatment is needed for COVID-19 patients with comorbid diabetes mellitus, especially for elderly people with diabetes mellitus. Neurologically, COVID-19 in the elderly with diabetes mellitus presents with headaches, dizziness, acute confusion, unorganized thinking, and incoherence (Deliwala et al., 2021 ). Fifteen percent of cases of covid 19 in hospitals stated that changes in consciousness as a neurological manifestation of COVID-19 were of various types, ranging from somnolence, confusion, delirium, stupor, to coma (Mao et al., 2020 ). Neurological changes in the elderly with diabetes mellitus with covid 19 need special attention in the treatment process. The incidence of delirium and acute confusion in COVID-19 occurs due to an imbalance of neurotransmitters, pro-inflammatory cytokines, tissue hypoxia, and lack of sleep (Pranata et al., 2021 ). Acute confusional conditions in elderly diabetes mellitus with COVID-19 have the potential to be an additional workload for health workers who provide care, as well as for families as caregivers if the elderly are self-quarantine at home. The infection transmission of COVID 19 was so powerful and fast that all the patients diagnosed with COVID-19 required a negative pressure isolation treatment room in the hospital during their treatment period. However, the limited capacity of the hospital has made most of patients diagnosed with COVID-19 receiving treatment in normal beds in hospitals. In the worst conditions, even normal beds were not sufficient in areas where mass infections occurred, some patients waiting for hospital admission mostly died in their homes during self-quarantine (Heo et al., 2021 ). In Indonesia, the highest death due to self-quarantine of COVID 19 at home occurred on July 27 2023 which 2,703 people (Lapor Covid 19, 2021 ). Low oxygen saturation on admission was reported as a strong predictor of mortality in COVID-19 patients (Mphekgwana et al., 2022 ). Sudden low oxygen saturation known as silent hypoxia or 'happy hypoxemia' has caused high mortality of COVID-19 patients during self-quarantine at home (Nandy et al., 2021 ). The family's limited knowledge of the causes of this mortality has led to a high death rate in COVID 19 during self-quarantine at home. The peak condition of covid 19 in mid-2021 made the health system in Indonesia a difficult condition, limited hospital capacity chose a family center nursing approach for the elderly with comorbidities who were self-quarantine at home to be one of the best choices at the peak of covid 19. Family Centered Nursing is the ability of nurses to provide family nursing care that aims to make family members independent in an effort to improve the health of all family members, so that families are able to overcome health problems experienced by their members (Fabanjo & Loihala, 2017 ). Family nursing is a good strategy to achieve better family health status with a positive correlation with increasing the ability of families to carry out their duties in maintaining, preventing and overcoming family health problems independently (Nuriyanto & Rahayuwati, 2019 ). In this case, the telenursing approach can make it easier for nurses to provide nursing care for the elderly who are self-quarantine for COVID-19 at home. When the elderly self-quarantine for COVID-19 at home, the family takes on the role of caregiver for the elderly. Through the family center telenursing approach, the ability of families as caregivers in carrying out family health tasks to care for the elderly during quarantine at home can be maximized (Balqis & Suryadin, 2022 ). Patient and family-centered care are seen as a high quality approach in healthcare settings. Flexibility in family nursing interventions (client and family centered) supports quality health services through effectiveness and efficiency in providing physical support for families, empowering families, and obtaining accurate client information (Park et al., 2018 ). Based on this background, the authors are interested in conducting further studies on family center nursing for an acute confusion in Diabetes Mellitus elderly with COVID-19 through the case report research method. This case report aims to describe the provision of family center nursing for an acute confusion of diabetes mellitus elderly with COVID-19 who are self-quarantine at home. METHOD This study uses a case report design of a diabetic elderly with Covid-19 who is doing self-quarantine with family as caregivers at home. This study was conducted through virtual observation using a remote counseling approach. This study was conducted from July 2021 to September 2021. The elderly and family use distance counseling for COVID 19 self quarantine with family as a caregiver for 14 days home quarantine. Through telenursing, the entire family nursing care process was recorded, including elderly health data, consultations, etc. The elderly and their families agreed to have their clinical cases published in an anonymous journal and signed an informed consent form. This patient consent for publication is an ethical permission for case report research (Stokes & Fertleman, 2015 ). According to the Indonesian Ministry of Health's instructions for self-quarantine in COVID-19 confirmed cases, family care nursing for the elderly is provided for a period of 14 days. Evaluation and analysis of the case report created using a telenursing methodology and based on NANDA-NOC-NIC International. RESULTS AND DISCUSSION CASE A family with a 65 years old man with a history of type 2 diabetes, chronic gastritis, and hypertension on June 11, 2021, contacted the telenursing service for covid 19 with symptoms of having 3 days of fever, chills, and coughing a cold. Because at that time Indonesia was in the second wave of COVID-19, the telenursing nurse team conducted a home service antigen swab examination as part of the service procedure during the pandemic, followed by a glucose level check to see the client's current glucose level. From the results of the antigen swab examination, it is known that the client and his wife (54 years old) are positive for COVID-19. The results of the glucose client's was 345mg/dl and blood pressure was 130/80 mmHg. The client and his wife are self-quarantine on the 2nd floor of their house, while other family members who are negative for covid 19 (1 son, 1 daughter-in-law, and 2 grandchildren) live on the 1st floor. When doing self-isolation, the client's wife took the role of a caregiver for clients. Twelve hours after being tested positive for COVID-19, client complained of a severe headache. Caregiver (client's wife) through the virtual monitoring feature in the telenursing program said that the client was restless, hallucinating (feeling that there was water running beside his bed), time disorientation, praying many times, pacing aimlessly, unable to sleep, and had difficulty eating. Based on family care nursing analysis through telenursing, clients health problems were acute confusion (Herdman et al., 2021 ). NURSING ASSESSMENT From nursing assessment, acute confusion was existent in the client, who also showed altered psychomotor functioning, poor follow-through with goal-directed behavior, poor follow-through with purposeful behavior, cognitive dysfunction, difficulty initiating goal-directed behavior, difficulty initiating purposeful behavior, hallucinations, and psychomotor agitation. NURSING INTERVENTIONS For 14 days of self-isolation, nursing intervention is carried out by telenursing nurse monitoring and home visits. On the first, second, and final days of the self-isolation period, home visits are conducted. The tables below detail nursing care, including monitoring client progress based on NANDA-NOC-NIC International method for acute confusion. Table 1 Nursing Care Plan of Client (A 65 Years Old Man) Nursing Diagnosis Nursing Outcomes Classification Nursing Intervention Classification Acute Confusion Decreased Agitation level (1214) from 3 (moderate) to 5 (none) on: 121403 Frustration 121404 Irritability 121405 Pacing 121432 Insomnia 121424 Inappropriate gestures Decreased Blood Glucose Level (2300) from 3 (moderate deviation from the norm) to 5 (no deviation from the norm)) on: 230001 Blood Glucose Decrease Vital Signs (0802) from 3 (moderate deviation from the norm) to 5 (no deviation from the norm) on: 080201 Body temperature 080203 Radial pulse rate 080204 Respiratory rate 080205 Systolic blood pressure 080206 Diastolic blood pressure Decreased Delirium Level (0916) from 3 (moderate) to 5 (none) on: 091604 Disorientation of time 091604 Psychomotor activity 091605 Impaired cognition 091606 Impaired memory 091607 Difficulty following complex commands 091608 Difficulty interpreting environmental stimuli 091609 Difficulty maintaining focus 091610 Difficulty maintaining conversation 091611 Misinterpretation 091612 Meaningless verbalizations 091615 Restlessness 091617 Disruption of sleep-wake pattern 091618 Labile mood 091620 Hallucinations 091621 Delusions FHT 1 Families are able to recognize acute confusion problems in the elderly through delirium management (6440), namely: - Together with family identify etiological factors causing delirium - Family recognize the motor subtype of the delirium (e.g., hypoactive, hyperactive, and mixed) FHT 2 Families are able to decide health problems related to acute confusion in the elderly through delirium management (6440), namely: - Family initiate therapies to reduce or eliminate factors causing the delirium - Provide caregivers (family members) who are familiar to the patient FHT 3 Families are able to independently care for acute confusional problems in the elderly through: Delirium management (6440), namely: - Instead of restraints, use family members to keep an eye on agitated patients. -Recognize the client's worries and feeling -Offer enthusiastic but realistic reassurance -Permit the client and family to practice rituals that reduce anxiety -Advise the client and family of what is occurring and what may be anticipated to happen in the future. - Limit need for decision making if frustrating or confusing to client - Encourage visitation by significant others, as appropriate (using covid 19 protocols) - Don't confirm a client in delirium's false perceptions or incorrect interpretations of reality (e.g., hallucinations or delusions) -Teach the caregiver to respond to the tone of the hallucination or delusion rather than the content in order to maintain calm, assurance, and non-argumentative communication. -Teach the caregiver to provide for the client's needs in terms of eating, bowel problems, hydration, and personal cleanliness. -Teach the caregiver to avoid upsetting the client by asking open-ended questions about orientation. -Teach caregiver to use environmental cues (such as signs, pictures, clocks, calendars, and color coding of the environment) to stimulate memory, reorient, and encourage appropriate behavior. - Teach caregiver to provide a consistent physical environment and daily routine. -Teach the caregiver to offer the patient a low-stimulation environment (for patients whose disorientation is exacerbated by overstimulation) and to introduce new information gradually in tiny doses with periodic rest times. - Instruct caregivers to center their conversations with patients on things they are familiar with and find significant. -Teach the caregiver how to speak in clear, concise, and descriptive terms. Vital Sign Monitor (6680), namely: - Monitor blood glucose level - Keep an eye on respiratory breath, temperature, pulse, and blood pressure as necessary. - Monitor Pulse Oximetry FHT 4 Sleep Enhancement (1850), namely: - Estimate the client's typical sleep/wake cycle with the family when planning care - Teach caregiver to encourage the client to establish a bedtime routine to ease the transition from wakefulness to sleep - Teach caregiver to help the client limit daytime sleep by providing activity that promotes wakefulness FHT 5 Medication Management (2380),namely: - Teach the caregiver the right drug administration technique. -Teach the caregiver the anticipated effects and potential side effects of the drug. NURSING OUTCOMES The condition of the second wave of the peak of covid 19 in mid-2021 put nurses in a difficult choice, limited hospital capacity made the choice of using telenursing with a family center nursing approach for the elderly with comorbidities who were self-quarantine at home to be one of the best choices in the community at that time (Balqis & Suryadin, 2022 ). In the application of family center nursing for an acute confusion in diabetes mellitus elderly with covid 19, the author uses a family health task approach in family center nursing by involving the caregiver (family member) in delirium management, vital sign monitoring, sleep enhancement, and medication management. Nursing intervension trought family center nursing is carried out through 5 Family Health Task (FHT) from Malaya Theory, namely recognizing the family member health problem (FHT 1), making decisions for appropriate treatment features (FHT 2), caring for sick family members (FHT 3), modifying the healthy environment (FHT 4), and utilizing the healthcare facilities (FHT 5) (Sukartini et al., 2020 ). Delirium Management The most prevalent problem affecting older patients being treated in hospitals is delirium, which is described as an acute disturbance in attention and cognition that develops over a short period of time. It causes significant morbidity and mortality (Hshieh et al., 2020 ). Delirium as a crucial diagnostic to detect people at increased risk of having negative COVID-19 results (Hariyanto et al., 2021 ). As health workers, nurses need to pay attention to the signs and symptoms of delirium in the elderly with COVID-19 as a serious symptom. In nursing, delirium management is provision of a therapeutic and safe atmosphere for the patient who is suffering from a severe case of disorientation (Butcher et al., 2018 ). In the condition of the COVID-19 elderly with delirium who are self-quarantine at home, telenursing nurses involve the role of caregiver (family member) in the nursing care provided. In this delirium condition, nurses and families work together to monitor the condition of the elderly through a delirium management approach according to the Nursing Intervention Classification (NIC) guidelines. Family caregivers have a significant role in the identification and treatment of delirium. (Shrestha & Fick, 2020 ). Caregivers (family members) have an important role in the health of the elderly who are self-quarantine from COVID-19 at home, especially for the elderly who experience delirium due to the COVID-19 infection. Caregivers provide essential physical and emotional care support to prevent deterioration, promote recovery, and facilitate rehabilitation for the elderly. As the closest person, the caregiver can see in-depth changes in the cognition of the elderly with COVID-19, for example monitoring changes in physical function (ADL) or changes in the behavior of the elderly. Caregivers can compare and differentiate the basic conditions of the elderly in their daily lives before being exposed to COVID-19 with conditions after being exposed to COVID-19, so that the process of detecting changes in the etcondition of delirium in the elderly with COVID-19 who is self-quarantine at home becomes easier. Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his delirium condition, including improvement in the condition of disorientation of time, psychomotor activity, impaired cognition, impaired memory, difficulty following complex commands, difficulty interpreting environmental stimuli, difficulty maintaining focus, difficulty maintaining conversation, misinterpretation, meaningless verbalizations, restlessness, disruption of sleep-wake pattern, labile mood, hallucinations, and delusions. Family caregivers providing interventions to patients with delirium can improve patient outcomes, including reducing the length of hospital stay, reducing anxiety, and ease of care for delirium patients so that the delirium condition can consistently decline during the treatment period (McKenzie & Joy, 2020 ). In the delirium management which is overcome through collaboration between nurses, family caregivers, and the elderly as clients, it is found that there are three burdens become the focus to be overcome together, namely symptom burdens (emotional burden (angry/frustration, emotional distress, fear, guilt, helplessness), situational burden (loss of control, lack of attention, lack of knowledge, lack of resources, safety concerns, unpredictability, unpreparedness), and behavioral burden (disorientation, hallucinations/delusions, impaired communication, memory problems, personality changes, sleep disturbances (Schmitt et al., 2019 ). Vital Signs Monitoring Vital signs monitoring is one of the nursing interventions for acute confusion listed in the Nursing Intervention Classification (NIC). Vital signs monitoring is the process of gathering and analyzing information on the body's heart, lungs, and temperature in order to identify and avoid complications (Kamei et al., 2021 ). Things that are recorded in the vital signs monitoring related to the condition of the client as an acute confusion diabetes mellitus elderly with covid 19 include blood pressure, HR, RR, body temperature, and blood glucose level. Feature of self-vital signs monitoring on telenursing can also increase caregiver independence in caring for the elderly with COVID-19 so that the treatment process can run effectively and maximally. Education in conducting vital signs monitoring for COVID-19 patients when self-quarantine at home through telenursing during the COVID-19 pandemic showed high satisfaction (4.71 points out of 5) and convenience (4.72 points out of 5) for COVID-19 patients, which means that the method was assessed effectively used in patient education or guidance when doing self-isolation at home (Heo et al., 2021 ). Using self-monitoring data of blood glucose level, blood pressure, HR, RR, and body temperature, caregivers can make decisions about the health status of the diabetes mellitus elderly covid 19 with an acute confusion. Vital signs monitoring independently by the family caregiver (after receiving guidance from the telenursing nurses) can help the telenursing nurses to better manage the health monitoring of their patients and maintain close contact with their patients' famili (Durán-Vega et al., 2019 ). Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his vital signs, including improvement in vital signs, diantaranya blood glucose level, blood pressure, pulse, temperature, respiratory status, and pulse oximetry. The evaluation found that the vital signs monitoring independently by caregiver improve the quality of the elderly's healthcare (Durán-Vega et al., 2019 ). Caregiver (family members)-initiated intensive vital sign monitoring can enhance the standard of nursing care for COVID-19 elderly who are self-quarantining at home and help the elderly recover as quickly as possible.. Sleep Enhancement One of the basic needs for elderly people that must be satisfied in order to maximize their quality of life is sleep. Sleep issues are one of the issues that are frequently discovered in elderly people with COVID-19. In the second COVID-19 wave, the prevalence of sleep disturbances among senior people with chronic conditions (i.e., diabetes, and cancer, cardiovascular disease and psychiatric disorders, pulmonary disease and neurological disorders) was reported to increase (Cipriani et al., 2021 ). An important factor in determining why elderly people are more likely to experience negative COVID-19 effects is their inherent sleep pattern and the common sleep disorders that affect this population, which include advanced sleep timing, a preference for the morning, increased sleep fragmentation, reduced slow-wave sleep, longer sleep-onset latency, shorter overall sleep duration, and increased wake time after sleep onset (Pires et al., 2021 ).These statements illustrate that sleep problems in the elderly with COVID-19 are a combination of the disease process and physiological aging of sleep in the elderly. The client in this study showed sleep problems related to acute confusion caused by a combination of diabetes mellitus and covid 19 problems. Acetylcholine and dopamine are crucial neurochemicals in the regulation of sleep and wakefulness, and their dysregulation has been implicated in the development of delirium. Sleep deprivation and delirium are strongly linked, with shared clinical manifestations, risk factors, and neurochemical abnormalities (Farasat et al., 2020 ). With various health problems that may accompany the elderly with covid 19, non-pharmacological therapy for sleep-disturbed elderly with covid 19 can improve the quality of sleep in the elderly by improving overall physical and mental health, and physical functioning (Zhu et al., 2021 ). It has been demonstrated that non-pharmacological techniques like nurse interventions with sleep enhancement can improve sleep quality and comfort (Han & Kim, 2021 ). Sleep Enhancement is one of the nursing interventions to overcome sleep deprivation in acute confusion listed in the Nursing Intervention Classification (NIC). In the nursing approach, sleep enhancement is defined as the facilitation of regular sleep/wake cycles (Butcher et al., 2018 ). Sleep problems in patients with Covid 19 include disrupted sleep (42.3%), falling asleep unintentionally (35.2%), difficulties falling (30.9%), staying asleep (30.8%) and later bedtimes (30.0%) (Pérez-Carbonell et al., 2020 ). Sleep disorders such as insomnia, REM sleep behavior disorder, changes in sleep/wake rhythm, sleep paralysis, to sleep disorder breathing in COVID-19 cases have increased at age 60 or above (Cha et al., 2022 ). The sleep enhancement approach as an effort to overcome sleep problems in the elderly with COVID-19 is considered quite effective to overcome this problem. Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his sleep problem, including improvement in insomnia, restlessness, and disruption of sleep-wake pattern. Overcoming sleep problems is one of the effective efforts to achieve maximum recovery in the elderly with COVID 19 Medication Management Medication management is one of the nursing interventions to overcome high blood glucose levels in acute confusion caused by DM as listed in the Nursing Intervention Classification (NIC). The nursing approach defines medication management as making it possible for people to use prescription and over-the-counter medications in a safe and effective manner (Butcher et al., 2018 ). Various chronic comorbidities are common in older persons, while polypharmacy and multiple medication use are frequent outcomes of multimorbidity.. (Wagle et al., 2018 ). Polypharmacy in the elderly was also experienced in the case of elderly Covid with comorbid DM in this study. Client's medications during self isolation COVID 19 include multivitamins, ulcer drugs, antipyretics, mucolytics, anti-inflammatory drugs, DM drugs, antibiotics, antivirals, and inhalation drugs. During the COVID-19 self-isolation period, family caregivers play a vital role in ensuring safe and appropriate medication use for the elderly. The data states that 55.9% of dependent elderly need assistance in medication management and 80.2% of caregivers say that information about medication management helps in the care of dependent patients (Dixe et al., 2019 ). In medication management with a family center nursing approach, caregivers were commonly involved in 2 types of activities, namely direct activities and indirect activities. Getting medications, making pill boxes, and helping with medication administration are examples of direct medication management tasks that require physical handling of medications. In contrast, indirect medication management tasks require more complex cognitive work from the caregiver, such as organizing and tracking medications, gathering data, and coming to treatment decisions. (Look & Stone, 2018 ). All medication management activities carried out by caregivers are under the supervision of the telenursing nurses. Telenursing is a simple method to provide and maintain nursing care for patients with chronic illness such as diabetes, especially in COVID 19 pandemic. Diabetes management can be challenging and risky for elderly people with cognitive issues who are unable to adhere to instructions and manage their own drug schedule (Leung et al., 2018 ). Telenursing through nurse-led telephone follow up can improve HbA1c and BMI in illiterate patients with type 2 diabetes who are 50 years of age and older. It can also promote adherence to the treatment program.(Shahsavari & Bakhshandeh Bavarsad, 2020 ). In line with these results, the client in this case report showed a decrease in blood glucose level after receiving medication management through telenursing. Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client showed a decrease in his blood glucose level (the first day 358 mg/dl, day 4 to day 14 is in the range of 120–150 mg/dl). This research has implications for the development of family nursing care and nursing education institutions in caring for self-quarantine in acute confusion of the elderly with COVID 19, including integrating nursing interventions such as delirium management, vital sign monitoring, sleep enhancement, and medication management into care family nursing. All family nursing care is carried out using the 5 family health task (FHT) approach in family center nursing, namely recognizing the family member health problem (FHT 1), making decisions for appropriate treatment features (FHT 2), caring for sick family members (FHT 3), modifying the healthy environment (FHT 4), and utilizing the healthcare facilities (FHT 5). LIMITATION OF THE STUDY While this case report study is considered appropriate for research that desires a holistic viewpoint and detailed data of one person's experiences, this research may limit the representative of multiple viewpoint CONCLUSIONS AND SUGGESTIONS The results study shows that family center nursing for acute confusion in diabetes mellitus elderly with covid 19 who received nursing intervention including delirium management, vital sign monitoring, sleep enhancement, and medication management experienced a decrease in agitation level, blood glucose level, and delirium level from the elderly. This study is expected to be a reference for related institutions to develop family center nursing for families with elderly COVID-19 problems Declarations ETHICAL CONSIDERATIONS The elderly and their family members had given their informed consent and consented to have their clinical case published anonymously in an academic journal. 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In Journal of Psychiatric Research (Vol. 142, pp. 361–368). https://doi.org/10.1016/j.jpsychires.2021.08.031 Heo, H., Lee, K., Jung, E., & Lee, H. (2021). Developing the first telenursing service for COVID-19 patients: The experience of South Korea. International Journal of Environmental Research and Public Health , 18 (13), 1–13. https://doi.org/10.3390/ijerph18136885 Herdman, H. T., Kamitsuru, S., & Takao Lopes, C. (2021). NANDA International, Inc. nursing diagnoses : definitions and classification . Hshieh, T. T., Inouye, S. K., & Oh, E. S. (2020). Delirium in the Elderly. Clinics in Geriatric Medicine , 36 (2), 183–199. https://doi.org/10.1016/j.cger.2019.11.001 Ji, D., Zhang, D., Xu, J., Chen, Z., Yang, T., Zhao, P., Chen, G., Cheng, G., Wang, Y., Bi, J., Tan, L., Lau, G., & Qin, E. (2020). Prediction for progression risk in patients with COVID-19 pneumonia: The CALL score. 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J., Wassermann, D., Gnoni, V., Leschziner, G., Weighall, A., Ellis, J., Durrant, S., Hare, A., & Steier, J. (2020). Impact of the novel coronavirus (COVID-19) pandemic on sleep. Journal of Thoracic Disease , 12 , S163–S175. https://doi.org/10.21037/JTD-CUS-2020-015 Pires, G. N., Ishikura, I. A., Xavier, S. D., Petrella, C., Piovezan, R. D., Xerfan, E. M. S., Andersen, M. L., & Tufik, S. (2021). Sleep in Older Adults and Its Possible Relations With COVID-19. Frontiers in Aging Neuroscience , 13 (June), 1–14. https://doi.org/10.3389/fnagi.2021.647875 Pranata, R., Huang, I., Lim, M. A., Yonas, E., Vania, R., & Kuswardhani, R. A. T. (2021). Delirium and Mortality in Coronavirus Disease 2019 (COVID-19) – A Systematic Review and Meta-analysis. Archives of Gerontology and Geriatrics , 95 (March), 104388. https://doi.org/10.1016/j.archger.2021.104388 Schmitt, E. M., Gallagher, J., Albuquerque, A., Tabloski, P., Lee, H. J., Gleason, L., Weiner, L. S., Marcantonio, E. R., Jones, R. N., Inouye, S. K., & Schulman-Green, D. (2019). Perspectives on the Delirium Experience and Its Burden: Common Themes among Older Patients, Their Family Caregivers, and Nurses. Gerontologist , 59 (2), 327–337. https://doi.org/10.1093/geront/gnx153 Sen, S., Chakraborty, R., Kalita, P., & Pathak, M. P. (2021). Diabetes mellitus and COVID-19: Understanding the association in light of current evidence. World Journal of Clinical Cases , 9 (28), 8327–8339. https://doi.org/10.12998/wjcc.v9.i28.8327 Shahsavari, A., & Bakhshandeh Bavarsad, M. (2020). Is Telenursing an Effective Method to Control BMI and HbA1c in Illiterate Patients Aged 50 Years and Older With Type 2 Diabetes? A Randomized Controlled Clinical Trial. Journal of Caring Sciences , 9 (2), 73–79. https://doi.org/10.34172/jcs.2020.011 Shrestha, P., & Fick, D. M. (2020). Family caregiver’s experience of caring for an older adult with delirium: A systematic review. International Journal of Older People Nursing , 15 (4), 1–17. https://doi.org/10.1111/opn.12321 Singh, A. K., Gupta, R., Ghosh, A., & Misra, A. (2020). Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes and Metabolic Syndrome: Clinical Research and Reviews , 14 (4), 303–310. https://doi.org/10.1016/j.dsx.2020.04.004 Stokes, V., & Fertleman, C. (2015). Writing a case report in 10 steps. BMJ , 350 , h2693. https://doi.org/10.1136/BMJ.H2693 Sukartini, T., Purwanti, N. D., & Mariyanti, H. (2020). Family Health Tasks Implementation and Medication Adherence of Pulmonary Tuberculosis Patients: A Correlational Study. Jurnal Ners , 15 (1), 49. https://doi.org/10.20473/jn.v15i1.8175 Wagle, K. C., Skopelja, E. N., & Campbell, N. L. (2018). Caregiver-Based Interventions to Optimize Medication Safety in Vulnerable Elderly Adults: A Systematic Evidence-Based Review. Journal of the American Geriatrics Society , 66 (11), 2128–2135. https://doi.org/10.1111/jgs.15556 WHO. (2022). Coronavirus disease (COVID-19) . https://www.who.int/health-topics/coronavirus#tab=tab_1 Zhu, X., Luo, Z., Chen, Y., Wang, L., Chi, W., Jiang, L. L., Liu, K., Zhao, L., Zhang, Y., & Zhang, H. (2021). Tai Chi for the elderly patients with COVID-19 in recovery period. Medicine , 100 (3), e24111. https://doi.org/10.1097/md.0000000000024111 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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08:04:21","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":138580,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7738924/v1/fb558ed2647f07b131776777.html"},{"id":92484216,"identity":"8c969be2-9651-4551-b43d-ba1c66e7e7d2","added_by":"auto","created_at":"2025-09-30 08:20:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":661230,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7738924/v1/51b0bcc1-0377-41a5-ae7b-c7abd23452bf.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFamily Center Nursing for An Acute Confusion in Diabetes Mellitus Elderly with COVID-19\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCoronavirus disease (Covid-19) is the highly contagious infectious disease caused by the SARS-CoV-2 virus which causes COVID-19 patients to experience mild to moderate respiratory illness which caused more than 6\u0026nbsp;million deaths worldwide, emerging as the most consequential global health crisis since the era of the influenza pandemic of 1918 (Cascella et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; WHO, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Along with comorbid diseases, COVID-19 is a disease with a high risk for those who are infected. Risk factors such as comorbidity, older age, lower lymphocyte count, and higher lactate dehydrogenase at presentation were independent high-risk factors for COVID-19 progression (Ji et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). From this explanation, the condition of the elderly causes the elderly with COVID-19 to become one of the groups with the highest morbidity and mortality. In Indonesia, 56% of deaths due to COVID-19 in January-March 2022 occurred in the elderly (Adisasmito, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The high rate of mortality and morbidity in the elderly covid 19 cases makes covid 19 a scourge for the elderly.\u003c/p\u003e\u003cp\u003eElderly and those with underlying medical conditions such as diabetes mellitus are more likely to develop serious illnesses. COVID-19 patients with DM are 14\u0026ndash;32% more at risk of experiencing severe or critical illness (Singh et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). High blood sugar was found to reduce immunity and increase the replication of SARS- CoV-2 while interacting with various other risk factors (Sen et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The pathogenesis of COVID-19 and diabetes mellitus includes effects on glucose homeostasis, inflammation, changes in immune status, and activation of the renin-angiotensin-aldosterone system (RAAS) (Lim et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This condition is the basis that more serious treatment is needed for COVID-19 patients with comorbid diabetes mellitus, especially for elderly people with diabetes mellitus.\u003c/p\u003e\u003cp\u003eNeurologically, COVID-19 in the elderly with diabetes mellitus presents with headaches, dizziness, acute confusion, unorganized thinking, and incoherence (Deliwala et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Fifteen percent of cases of covid 19 in hospitals stated that changes in consciousness as a neurological manifestation of COVID-19 were of various types, ranging from somnolence, confusion, delirium, stupor, to coma (Mao et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Neurological changes in the elderly with diabetes mellitus with covid 19 need special attention in the treatment process. The incidence of delirium and acute confusion in COVID-19 occurs due to an imbalance of neurotransmitters, pro-inflammatory cytokines, tissue hypoxia, and lack of sleep (Pranata et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Acute confusional conditions in elderly diabetes mellitus with COVID-19 have the potential to be an additional workload for health workers who provide care, as well as for families as caregivers if the elderly are self-quarantine at home.\u003c/p\u003e\u003cp\u003eThe infection transmission of COVID 19 was so powerful and fast that all the patients diagnosed with COVID-19 required a negative pressure isolation treatment room in the hospital during their treatment period. However, the limited capacity of the hospital has made most of patients diagnosed with COVID-19 receiving treatment in normal beds in hospitals. In the worst conditions, even normal beds were not sufficient in areas where mass infections occurred, some patients waiting for hospital admission mostly died in their homes during self-quarantine (Heo et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In Indonesia, the highest death due to self-quarantine of COVID 19 at home occurred on July 27 2023 which 2,703 people (Lapor Covid 19, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Low oxygen saturation on admission was reported as a strong predictor of mortality in COVID-19 patients (Mphekgwana et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Sudden low oxygen saturation known as silent hypoxia or 'happy hypoxemia' has caused high mortality of COVID-19 patients during self-quarantine at home (Nandy et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The family's limited knowledge of the causes of this mortality has led to a high death rate in COVID 19 during self-quarantine at home.\u003c/p\u003e\u003cp\u003eThe peak condition of covid 19 in mid-2021 made the health system in Indonesia a difficult condition, limited hospital capacity chose a family center nursing approach for the elderly with comorbidities who were self-quarantine at home to be one of the best choices at the peak of covid 19. Family Centered Nursing is the ability of nurses to provide family nursing care that aims to make family members independent in an effort to improve the health of all family members, so that families are able to overcome health problems experienced by their members (Fabanjo \u0026amp; Loihala, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Family nursing is a good strategy to achieve better family health status with a positive correlation with increasing the ability of families to carry out their duties in maintaining, preventing and overcoming family health problems independently (Nuriyanto \u0026amp; Rahayuwati, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In this case, the telenursing approach can make it easier for nurses to provide nursing care for the elderly who are self-quarantine for COVID-19 at home. When the elderly self-quarantine for COVID-19 at home, the family takes on the role of caregiver for the elderly. Through the family center telenursing approach, the ability of families as caregivers in carrying out family health tasks to care for the elderly during quarantine at home can be maximized (Balqis \u0026amp; Suryadin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Patient and family-centered care are seen as a high quality approach in healthcare settings. Flexibility in family nursing interventions (client and family centered) supports quality health services through effectiveness and efficiency in providing physical support for families, empowering families, and obtaining accurate client information (Park et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Based on this background, the authors are interested in conducting further studies on family center nursing for an acute confusion in Diabetes Mellitus elderly with COVID-19 through the case report research method. This case report aims to describe the provision of family center nursing for an acute confusion of diabetes mellitus elderly with COVID-19 who are self-quarantine at home.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cp\u003eThis study uses a case report design of a diabetic elderly with Covid-19 who is doing self-quarantine with family as caregivers at home. This study was conducted through virtual observation using a remote counseling approach. This study was conducted from July 2021 to September 2021. The elderly and family use distance counseling for COVID 19 self quarantine with family as a caregiver for 14 days home quarantine. Through telenursing, the entire family nursing care process was recorded, including elderly health data, consultations, etc. The elderly and their families agreed to have their clinical cases published in an anonymous journal and signed an informed consent form. This patient consent for publication is an ethical permission for case report research (Stokes \u0026amp; Fertleman, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). According to the Indonesian Ministry of Health's instructions for self-quarantine in COVID-19 confirmed cases, family care nursing for the elderly is provided for a period of 14 days. Evaluation and analysis of the case report created using a telenursing methodology and based on NANDA-NOC-NIC International.\u003c/p\u003e"},{"header":"RESULTS AND DISCUSSION","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eCASE\u003c/h2\u003e\u003cp\u003eA family with a 65 years old man with a history of type 2 diabetes, chronic gastritis, and hypertension on June 11, 2021, contacted the telenursing service for covid 19 with symptoms of having 3 days of fever, chills, and coughing a cold. Because at that time Indonesia was in the second wave of COVID-19, the telenursing nurse team conducted a home service antigen swab examination as part of the service procedure during the pandemic, followed by a glucose level check to see the client's current glucose level. From the results of the antigen swab examination, it is known that the client and his wife (54 years old) are positive for COVID-19. The results of the glucose client's was 345mg/dl and blood pressure was 130/80 mmHg. The client and his wife are self-quarantine on the 2nd floor of their house, while other family members who are negative for covid 19 (1 son, 1 daughter-in-law, and 2 grandchildren) live on the 1st floor. When doing self-isolation, the client's wife took the role of a caregiver for clients. Twelve hours after being tested positive for COVID-19, client complained of a severe headache. Caregiver (client's wife) through the virtual monitoring feature in the telenursing program said that the client was restless, hallucinating (feeling that there was water running beside his bed), time disorientation, praying many times, pacing aimlessly, unable to sleep, and had difficulty eating. Based on family care nursing analysis through telenursing, clients health problems were acute confusion (Herdman et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eNURSING ASSESSMENT\u003c/h3\u003e\n\u003cp\u003eFrom nursing assessment, acute confusion was existent in the client, who also showed altered psychomotor functioning, poor follow-through with goal-directed behavior, poor follow-through with purposeful behavior, cognitive dysfunction, difficulty initiating goal-directed behavior, difficulty initiating purposeful behavior, hallucinations, and psychomotor agitation.\u003c/p\u003e\n\u003ch3\u003eNURSING INTERVENTIONS\u003c/h3\u003e\n\u003cp\u003eFor 14 days of self-isolation, nursing intervention is carried out by telenursing nurse monitoring and home visits. On the first, second, and final days of the self-isolation period, home visits are conducted. The tables below detail nursing care, including monitoring client progress based on NANDA-NOC-NIC International method for acute confusion.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eNursing Care Plan of Client (A 65 Years Old Man)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing Diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNursing Outcomes Classification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNursing Intervention Classification\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAcute Confusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDecreased Agitation level (1214) from 3 (moderate) to 5 (none) on: \u003c/p\u003e\u003cp\u003e121403 Frustration\u003c/p\u003e\u003cp\u003e121404 Irritability \u003c/p\u003e\u003cp\u003e121405 Pacing \u003c/p\u003e\u003cp\u003e121432 Insomnia\u003c/p\u003e\u003cp\u003e121424 Inappropriate gestures\u003c/p\u003e\u003cp\u003eDecreased Blood Glucose Level (2300) from 3 (moderate deviation from the norm) to 5 (no deviation from the norm)) on:\u003c/p\u003e\u003cp\u003e230001 Blood Glucose\u003c/p\u003e\u003cp\u003eDecrease Vital Signs (0802) from 3 (moderate deviation from the norm) to 5 (no deviation from the norm) on:\u003c/p\u003e\u003cp\u003e080201 Body temperature\u003c/p\u003e\u003cp\u003e080203 Radial pulse rate\u003c/p\u003e\u003cp\u003e080204 Respiratory rate\u003c/p\u003e\u003cp\u003e080205 Systolic blood pressure\u003c/p\u003e\u003cp\u003e080206 Diastolic blood pressure\u003c/p\u003e\u003cp\u003eDecreased Delirium Level (0916) from 3 (moderate) to 5 (none) on:\u003c/p\u003e\u003cp\u003e091604 Disorientation of time \u003c/p\u003e\u003cp\u003e091604 Psychomotor activity \u003c/p\u003e\u003cp\u003e091605 Impaired cognition 091606 Impaired memory\u003c/p\u003e\u003cp\u003e091607 Difficulty following complex commands\u003c/p\u003e\u003cp\u003e091608 Difficulty interpreting environmental stimuli \u003c/p\u003e\u003cp\u003e091609 Difficulty maintaining focus \u003c/p\u003e\u003cp\u003e091610 Difficulty maintaining conversation\u003c/p\u003e\u003cp\u003e091611 Misinterpretation\u003c/p\u003e\u003cp\u003e091612 Meaningless verbalizations \u003c/p\u003e\u003cp\u003e091615 Restlessness \u003c/p\u003e\u003cp\u003e091617 Disruption of sleep-wake pattern \u003c/p\u003e\u003cp\u003e091618 Labile mood \u003c/p\u003e\u003cp\u003e091620 Hallucinations\u003c/p\u003e\u003cp\u003e091621 Delusions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFHT 1\u003c/p\u003e\u003cp\u003eFamilies are able to recognize acute confusion problems in the elderly through delirium management (6440), namely: \u003c/p\u003e\u003cp\u003e- Together with family identify etiological factors causing delirium \u003c/p\u003e\u003cp\u003e- Family recognize the motor subtype of the delirium (e.g., hypoactive, hyperactive, and mixed)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFHT 2 \u003c/p\u003e\u003cp\u003eFamilies are able to decide health problems related to acute confusion in the elderly through delirium management (6440), namely: \u003c/p\u003e\u003cp\u003e- Family initiate therapies to reduce or eliminate factors causing the delirium \u003c/p\u003e\u003cp\u003e- Provide caregivers (family members) who are familiar to the patient\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFHT 3\u003c/p\u003e\u003cp\u003eFamilies are able to independently care for acute confusional problems in the elderly through: Delirium management (6440), namely:\u003c/p\u003e\u003cp\u003e- Instead of restraints, use family members to keep an eye on agitated patients.\u003c/p\u003e\u003cp\u003e-Recognize the client's worries and feeling\u003c/p\u003e\u003cp\u003e-Offer enthusiastic but realistic reassurance\u003c/p\u003e\u003cp\u003e-Permit the client and family to practice rituals that reduce anxiety\u003c/p\u003e\u003cp\u003e-Advise the client and family of what is occurring and what may be anticipated to happen in the future.\u003c/p\u003e\u003cp\u003e- Limit need for decision making if frustrating or confusing to client \u003c/p\u003e\u003cp\u003e- Encourage visitation by significant others, as appropriate (using covid 19 protocols) \u003c/p\u003e\u003cp\u003e- Don't confirm a client in delirium's false perceptions or incorrect interpretations of reality (e.g., hallucinations or delusions)\u003c/p\u003e\u003cp\u003e-Teach the caregiver to respond to the tone of the hallucination or delusion rather than the content in order to maintain calm, assurance, and non-argumentative communication.\u003c/p\u003e\u003cp\u003e-Teach the caregiver to provide for the client's needs in terms of eating, bowel problems, hydration, and personal cleanliness.\u003c/p\u003e \u003cp\u003e-Teach the caregiver to avoid upsetting the client by asking open-ended questions about orientation.\u003c/p\u003e\u003cp\u003e-Teach caregiver to use environmental cues (such as signs, pictures, clocks, calendars, and color coding of the environment) to stimulate memory, reorient, and encourage appropriate behavior.\u003c/p\u003e \u003cp\u003e- Teach caregiver to provide a consistent physical environment and daily routine.\u003c/p\u003e\u003cp\u003e-Teach the caregiver to offer the patient a low-stimulation environment (for patients whose disorientation is exacerbated by overstimulation) and to introduce new information gradually in tiny doses with periodic rest times.\u003c/p\u003e\u003cp\u003e- Instruct caregivers to center their conversations with patients on things they are familiar with and find significant.\u003c/p\u003e\u003cp\u003e-Teach the caregiver how to speak in clear, concise, and descriptive terms.\u003c/p\u003e\u003cp\u003eVital Sign Monitor (6680), namely:\u003c/p\u003e\u003cp\u003e- Monitor blood glucose level\u003c/p\u003e\u003cp\u003e- Keep an eye on respiratory breath, temperature, pulse, and blood pressure as necessary.\u003c/p\u003e\u003cp\u003e- Monitor Pulse Oximetry\u003c/p\u003e\u003cp\u003e\u003cb\u003eFHT 4\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSleep Enhancement (1850), namely:\u003c/p\u003e\u003cp\u003e- Estimate the client's typical sleep/wake cycle with the family when planning care\u003c/p\u003e\u003cp\u003e- Teach caregiver to encourage the client to establish a bedtime routine to ease the transition from wakefulness to sleep\u003c/p\u003e \u003cp\u003e- Teach caregiver to help the client limit daytime sleep by providing activity that promotes wakefulness\u003c/p\u003e\u003cp\u003e\u003cb\u003eFHT 5\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMedication Management (2380),namely:\u003c/p\u003e\u003cp\u003e- Teach the caregiver the right drug administration technique.\u003c/p\u003e \u003cp\u003e-Teach the caregiver the anticipated effects and potential side effects of the drug.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eNURSING OUTCOMES\u003c/h2\u003e\n\u003cp\u003e\u003cimg 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\" width=\"550\" height=\"473\"\u003e\u003c/p\u003e\n\u003cp\u003eThe condition of the second wave of the peak of covid 19 in mid-2021 put nurses in a difficult choice, limited hospital capacity made the choice of using telenursing with a family center nursing approach for the elderly with comorbidities who were self-quarantine at home to be one of the best choices in the community at that time (Balqis \u0026amp; Suryadin, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In the application of family center nursing for an acute confusion in diabetes mellitus elderly with covid 19, the author uses a family health task approach in family center nursing by involving the caregiver (family member) in delirium management, vital sign monitoring, sleep enhancement, and medication management. Nursing intervension trought family center nursing is carried out through 5 Family Health Task (FHT) from Malaya Theory, namely recognizing the family member health problem (FHT 1), making decisions for appropriate treatment features (FHT 2), caring for sick family members (FHT 3), modifying the healthy environment (FHT 4), and utilizing the healthcare facilities (FHT 5) (Sukartini et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDelirium Management\u003c/h3\u003e\n\u003cp\u003eThe most prevalent problem affecting older patients being treated in hospitals is delirium, which is described as an acute disturbance in attention and cognition that develops over a short period of time. It causes significant morbidity and mortality (Hshieh et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Delirium as a crucial diagnostic to detect people at increased risk of having negative COVID-19 results (Hariyanto et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As health workers, nurses need to pay attention to the signs and symptoms of delirium in the elderly with COVID-19 as a serious symptom. In nursing, delirium management is provision of a therapeutic and safe atmosphere for the patient who is suffering from a severe case of disorientation (Butcher et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the condition of the COVID-19 elderly with delirium who are self-quarantine at home, telenursing nurses involve the role of caregiver (family member) in the nursing care provided. In this delirium condition, nurses and families work together to monitor the condition of the elderly through a delirium management approach according to the Nursing Intervention Classification (NIC) guidelines. Family caregivers have a significant role in the identification and treatment of delirium. (Shrestha \u0026amp; Fick, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCaregivers (family members) have an important role in the health of the elderly who are self-quarantine from COVID-19 at home, especially for the elderly who experience delirium due to the COVID-19 infection. Caregivers provide essential physical and emotional care support to prevent deterioration, promote recovery, and facilitate rehabilitation for the elderly. As the closest person, the caregiver can see in-depth changes in the cognition of the elderly with COVID-19, for example monitoring changes in physical function (ADL) or changes in the behavior of the elderly. Caregivers can compare and differentiate the basic conditions of the elderly in their daily lives before being exposed to COVID-19 with conditions after being exposed to COVID-19, so that the process of detecting changes in the etcondition of delirium in the elderly with COVID-19 who is self-quarantine at home becomes easier.\u003c/p\u003e\u003cp\u003eBased on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his delirium condition, including improvement in the condition of disorientation of time, psychomotor activity, impaired cognition, impaired memory, difficulty following complex commands, difficulty interpreting environmental stimuli, difficulty maintaining focus, difficulty maintaining conversation, misinterpretation, meaningless verbalizations, restlessness, disruption of sleep-wake pattern, labile mood, hallucinations, and delusions. Family caregivers providing interventions to patients with delirium can improve patient outcomes, including reducing the length of hospital stay, reducing anxiety, and ease of care for delirium patients so that the delirium condition can consistently decline during the treatment period (McKenzie \u0026amp; Joy, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In the delirium management which is overcome through collaboration between nurses, family caregivers, and the elderly as clients, it is found that there are three burdens become the focus to be overcome together, namely symptom burdens (emotional burden (angry/frustration, emotional distress, fear, guilt, helplessness), situational burden (loss of control, lack of attention, lack of knowledge, lack of resources, safety concerns, unpredictability, unpreparedness), and behavioral burden (disorientation, hallucinations/delusions, impaired communication, memory problems, personality changes, sleep disturbances (Schmitt et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eVital Signs Monitoring\u003c/h2\u003e\u003cp\u003eVital signs monitoring is one of the nursing interventions for acute confusion listed in the Nursing Intervention Classification (NIC). Vital signs monitoring is the process of gathering and analyzing information on the body's heart, lungs, and temperature in order to identify and avoid complications (Kamei et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Things that are recorded in the vital signs monitoring related to the condition of the client as an acute confusion diabetes mellitus elderly with covid 19 include blood pressure, HR, RR, body temperature, and blood glucose level. Feature of self-vital signs monitoring on telenursing can also increase caregiver independence in caring for the elderly with COVID-19 so that the treatment process can run effectively and maximally. Education in conducting vital signs monitoring for COVID-19 patients when self-quarantine at home through telenursing during the COVID-19 pandemic showed high satisfaction (4.71 points out of 5) and convenience (4.72 points out of 5) for COVID-19 patients, which means that the method was assessed effectively used in patient education or guidance when doing self-isolation at home (Heo et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUsing self-monitoring data of blood glucose level, blood pressure, HR, RR, and body temperature, caregivers can make decisions about the health status of the diabetes mellitus elderly covid 19 with an acute confusion. Vital signs monitoring independently by the family caregiver (after receiving guidance from the telenursing nurses) can help the telenursing nurses to better manage the health monitoring of their patients and maintain close contact with their patients' famili (Dur\u0026aacute;n-Vega et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBased on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his vital signs, including improvement in vital signs, diantaranya blood glucose level, blood pressure, pulse, temperature, respiratory status, and pulse oximetry. The evaluation found that the vital signs monitoring independently by caregiver improve the quality of the elderly's healthcare (Dur\u0026aacute;n-Vega et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Caregiver (family members)-initiated intensive vital sign monitoring can enhance the standard of nursing care for COVID-19 elderly who are self-quarantining at home and help the elderly recover as quickly as possible..\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eSleep Enhancement\u003c/h2\u003e\u003cp\u003eOne of the basic needs for elderly people that must be satisfied in order to maximize their quality of life is sleep. Sleep issues are one of the issues that are frequently discovered in elderly people with COVID-19. In the second COVID-19 wave, the prevalence of sleep disturbances among senior people with chronic conditions (i.e., diabetes, and cancer, cardiovascular disease and psychiatric disorders, pulmonary disease and neurological disorders) was reported to increase (Cipriani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). An important factor in determining why elderly people are more likely to experience negative COVID-19 effects is their inherent sleep pattern and the common sleep disorders that affect this population, which include advanced sleep timing, a preference for the morning, increased sleep fragmentation, reduced slow-wave sleep, longer sleep-onset latency, shorter overall sleep duration, and increased wake time after sleep onset (Pires et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).These statements illustrate that sleep problems in the elderly with COVID-19 are a combination of the disease process and physiological aging of sleep in the elderly.\u003c/p\u003e\u003cp\u003eThe client in this study showed sleep problems related to acute confusion caused by a combination of diabetes mellitus and covid 19 problems. Acetylcholine and dopamine are crucial neurochemicals in the regulation of sleep and wakefulness, and their dysregulation has been implicated in the development of delirium. Sleep deprivation and delirium are strongly linked, with shared clinical manifestations, risk factors, and neurochemical abnormalities (Farasat et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). With various health problems that may accompany the elderly with covid 19, non-pharmacological therapy for sleep-disturbed elderly with covid 19 can improve the quality of sleep in the elderly by improving overall physical and mental health, and physical functioning (Zhu et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt has been demonstrated that non-pharmacological techniques like nurse interventions with sleep enhancement can improve sleep quality and comfort (Han \u0026amp; Kim, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Sleep Enhancement is one of the nursing interventions to overcome sleep deprivation in acute confusion listed in the Nursing Intervention Classification (NIC). In the nursing approach, sleep enhancement is defined as the facilitation of regular sleep/wake cycles (Butcher et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSleep problems in patients with Covid 19 include disrupted sleep (42.3%), falling asleep unintentionally (35.2%), difficulties falling (30.9%), staying asleep (30.8%) and later bedtimes (30.0%) (P\u0026eacute;rez-Carbonell et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Sleep disorders such as insomnia, REM sleep behavior disorder, changes in sleep/wake rhythm, sleep paralysis, to sleep disorder breathing in COVID-19 cases have increased at age 60 or above (Cha et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The sleep enhancement approach as an effort to overcome sleep problems in the elderly with COVID-19 is considered quite effective to overcome this problem. Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client experienced an improvement in his sleep problem, including improvement in insomnia, restlessness, and disruption of sleep-wake pattern. Overcoming sleep problems is one of the effective efforts to achieve maximum recovery in the elderly with COVID 19\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMedication Management\u003c/h2\u003e\u003cp\u003eMedication management is one of the nursing interventions to overcome high blood glucose levels in acute confusion caused by DM as listed in the Nursing Intervention Classification (NIC). The nursing approach defines medication management as making it possible for people to use prescription and over-the-counter medications in a safe and effective manner (Butcher et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Various chronic comorbidities are common in older persons, while polypharmacy and multiple medication use are frequent outcomes of multimorbidity.. (Wagle et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Polypharmacy in the elderly was also experienced in the case of elderly Covid with comorbid DM in this study. Client's medications during self isolation COVID 19 include multivitamins, ulcer drugs, antipyretics, mucolytics, anti-inflammatory drugs, DM drugs, antibiotics, antivirals, and inhalation drugs.\u003c/p\u003e\u003cp\u003eDuring the COVID-19 self-isolation period, family caregivers play a vital role in ensuring safe and appropriate medication use for the elderly. The data states that 55.9% of dependent elderly need assistance in medication management and 80.2% of caregivers say that information about medication management helps in the care of dependent patients (Dixe et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In medication management with a family center nursing approach, caregivers were commonly involved in 2 types of activities, namely direct activities and indirect activities. Getting medications, making pill boxes, and helping with medication administration are examples of direct medication management tasks that require physical handling of medications. In contrast, indirect medication management tasks require more complex cognitive work from the caregiver, such as organizing and tracking medications, gathering data, and coming to treatment decisions. (Look \u0026amp; Stone, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll medication management activities carried out by caregivers are under the supervision of the telenursing nurses. Telenursing is a simple method to provide and maintain nursing care for patients with chronic illness such as diabetes, especially in COVID 19 pandemic. Diabetes management can be challenging and risky for elderly people with cognitive issues who are unable to adhere to instructions and manage their own drug schedule (Leung et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Telenursing through nurse-led telephone follow up can improve HbA1c and BMI in illiterate patients with type 2 diabetes who are 50 years of age and older. It can also promote adherence to the treatment program.(Shahsavari \u0026amp; Bakhshandeh Bavarsad, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In line with these results, the client in this case report showed a decrease in blood glucose level after receiving medication management through telenursing. Based on the Nursing Outcomes Classification (NOC) for 14 days, a family center nursing approach through telenursing obtained data that the client showed a decrease in his blood glucose level (the first day 358 mg/dl, day 4 to day 14 is in the range of 120\u0026ndash;150 mg/dl).\u003c/p\u003e\u003cp\u003eThis research has implications for the development of family nursing care and nursing education institutions in caring for self-quarantine in acute confusion of the elderly with COVID 19, including integrating nursing interventions such as delirium management, vital sign monitoring, sleep enhancement, and medication management into care family nursing. All family nursing care is carried out using the 5 family health task (FHT) approach in family center nursing, namely recognizing the family member health problem (FHT 1), making decisions for appropriate treatment features (FHT 2), caring for sick family members (FHT 3), modifying the healthy environment (FHT 4), and utilizing the healthcare facilities (FHT 5).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLIMITATION OF THE STUDY\u003c/h2\u003e\u003cp\u003eWhile this case report study is considered appropriate for research that desires a holistic viewpoint and detailed data of one person's experiences, this research may limit the representative of multiple viewpoint\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSIONS AND SUGGESTIONS","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003cp\u003eThe results study shows that family center nursing for acute confusion in diabetes mellitus elderly with covid 19 who received nursing intervention including delirium management, vital sign monitoring, sleep enhancement, and medication management experienced a decrease in agitation level, blood glucose level, and delirium level from the elderly. This study is expected to be a reference for related institutions to develop family center nursing for families with elderly COVID-19 problems\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eETHICAL CONSIDERATIONS\u003c/h2\u003e\n \u003cp\u003eThe elderly and their family members had given their informed consent and consented to have their clinical case published anonymously in an academic journal. An ethical clearance has been given for the case report study with this patient consent for publishing (Stokes \u0026amp; Fertleman, \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eConflict of Interest Statement\u003c/h2\u003e\n\u003cp\u003eAccording to the authors, this study had no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding Statement.\u003c/h2\u003e\n\u003cp\u003eThere is no external funding done for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdisasmito. (2022). \u003cem\u003eKasus Kematian akibat Covid-19 di Indonesia Masih Tinggi, Lansia Mendominasi\u003c/em\u003e. Kompas.com. https://www.kompas.com/tren/read/2022/03/15/070300365/kasus-kematian-akibat-covid-19-di-indonesia-masih-tinggi-lansia-mendominasi?page=all\u003c/li\u003e\n \u003cli\u003eBalqis, U. M., \u0026amp; Suryadin, A. (2022). 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Tai Chi for the elderly patients with COVID-19 in recovery period. \u003cem\u003eMedicine\u003c/em\u003e, \u003cem\u003e100\u003c/em\u003e(3), e24111. https://doi.org/10.1097/md.0000000000024111\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Universitas Jember","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute Confusion, Covid 19, Diabetes Mellitus, Elderly, Family Center Nursing","lastPublishedDoi":"10.21203/rs.3.rs-7738924/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7738924/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCOVID 19 is an infectious disease caused by the SARS-CoV-2 virus. Neurologically, COVID-19 in the elderly with diabetes mellitus presents with headaches, dizziness, acute confusion, unorganized thinking, and incoherence. The research aims of this study are to describe a comprehensive family center nursing for families with acute confusion in diabetes mellitus elderly covid 19. The Method of this study uses a case report design in 1 case diabetes mellitus elderly covid 19 who live with family during self-quarantine of covid 19. Observation and analysis of the case report based on NANDA-NOC-NIC International that was carried out through a telenursing approach. The results study shows that family center nursing for acute confusion in diabetes mellitus elderly with covid 19 who received nursing intervention including delirium management, vital sign monitoring, sleep enhancement, and medication management experienced a decrease in agitation level, blood glucose level, and delirium level from the elderly. This study is expected to be a reference for related institutions to develop family center nursing for families with elderly COVID-19 problems\u003c/p\u003e","manuscriptTitle":"Family Center Nursing for An Acute Confusion in Diabetes Mellitus Elderly with COVID-19","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 08:04:16","doi":"10.21203/rs.3.rs-7738924/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0429149-14be-4ac1-b2c1-07fc9c665fb0","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-30T08:04:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 08:04:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7738924","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7738924","identity":"rs-7738924","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}