Delirium Flashcards
Cognition
brains ability to process, retain, and use information
Cognitive Abilities
reasoning, judgment, perception, attention, comprehension, and memory
-essential for making decisions, solving problems, interpreting the environment, and learning new information
Cognitive Disorder
disruption or impairment in these higher level functions of the brain
-disruption of cognitive abilities
Delirium
a syndrome that involves an acute disturbance of consciousness accompanied by a change in cognition
- develops over a short period
- have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations
Examples of Illusion
an electrical cord on the ground may appear to them as a snake
Example of Misinterpretation
may mistake the banging of a laundry cart in the hallway for a gunshot
Example of Hallucination
may see “angels” hovering above them when nothing is there
Onset of Delirium
rapid
Duration of Delirium
brief
-1 week; rarely more than 1 month
Delirium: State of Awareness
- impaired
- fluctuates from heightened awareness to environmental stimuli, vivid dreams, and nightmares
Delirium: Memory
-short-term memory impaired
Delirium: Speech
may be slurred, rambling, pressured, or irrelevant
Delirium: Thought Process
temporarily disorganized
Delirium: Perception
visual or tactile hallucinations
Delirium: Emotions
anxious, irritable, crying, apathy (lack of interest)
Delirium: Psychomotor Activity
agitated, restless, hyperactive, striking out
Predisposing Factors ( at risk of developing a problem)
- systemic infections
- febrile illness
- electrolyte imbalance
- hypoxia (absence of enough oxygen)
- hepatic or renal failure
- head trauma
- seizures
- migraine headaches
- brain abscess or brain neoplasms
- stroke
- nutritional deficiencies
- uncontrolled pain
- heat stroke
- burns
- cardiac issues
Etiology
almost always results from an identifiable physiological, metabolic, or cerebral disturbance or disease from drug intoxication or withdrawal
Risk Factors
- increased severity of physical illness
- older age
- hearing impairment
- decreased food and fluid intake
- medications
- baseline cognitive impairment such as that seen in dementia
Causes of Delirium: Physiological or Metabolic
- hypoxemia (low level of oxygen in the blood)
- electrolyte disturbances
- renal or hepatic failure
- thyroid or glucocorticoid disturbances
- thiamine or vitamin B12 deficiency
- vitamin C, niacin, or protein deficiency
- cardiovascular shock
- brain tumor
- head injury
- exposure to gas, paint solvents, insecticides, ad related substances
Causes of Delirium
multiple stressors
- trauma to CNS
- drug toxicity or withdrawal
- metabolic disturbances related to organ failure
- requires a careful and thorough physical examination and laboratory tests for identification
Cause of Delirium: Infection
- Systemic: sepsis, urinary tract infection, pneumonia
- Cerebral: meningitis, encephalitis, HIV, syphilis
Cause of Delirium: Drug Related
- Intoxication: anti-cholinergic, lithium, alcohol, sedatives, and hypnotics
- Withdrawal: alcohol, sedatives, and hypnotics
- reactions to anesthesia, prescription medication or illicit (street) drugs
Treatment and Prognosis
- identify and treat any causal or contributing medical conditions
- a transient condition that clears with successful treatment of the underlying cause
- some causes such as head injury or encephalitis may leave clients with cognitive, behavioral, or emotional impairments even when the underlying cause is resolved
Psychopharmacology
- clients with quiet, hypoactive delirium need no specific pharmacologic treatment aside from that indicated for causative condition
- agitation can interfere with safety and effective treatment; sedation to prevent inadvertent self-injury may be indicated
- anti-psychotic medicine, such as Haloperidol, may be used
- sedatives and benzodiazepines are avoided because they worsen delirium
Haloperidol
- anti-psychotic
- in doses of 0.5mg to 1 mg to decrease agitation and psychotic symptoms, as well as to facilitate sleep
- administered orally, IM, or IV
Other Medical Treatment
- adequate nutritious food and fluid intake speed recovery
- IV fluids or even total parenteral nutrition may be necessary if a clients physical condition has deteriorated and he/she cannot drink
- if client becomes agitated and threatens to dislodge IV or catheters, physical restraints may be necessary so needed medical treatments can continue; restraints can make a client agitated
Application of The Nursing Process Focuses On?
meeting physiological and psychological needs
Nursing Process: History
- thorough history of medical illness, alcohol, or other drugs
- may need to gather from family if ability to provide accurate data is impaired
General Appearance and Motor Behavior
- disturbance of psychomotor behavior
- restless or hyperactive, frequently picking at bed or clothes, or making sudden, uncoordinated attempts to get out of bed
- could have slow motor behavior, appearing sluggish and lethargic with little movement
- speech can be affected as delirium worsens
- rambling, difficult to follow, pressured speech
- may call out or scream; especially at night
Mood and Affect
- rapid and unpredictable mood shifts
- wide range of emotional responses
- nothing to do with clients environment
- when fearful and feel threatened; they may become combative to defend themselves
Thought Processes and Content
- disorganized and makes no sense
- difficult for the nurse to assess
- thoughts may be fragmented
- unrelated to situation
- speech is illogical and difficult to understand
Sensorium and Intellectual Processes
- primary and initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day
- oriented to people but disoriented to time and place
- decreased awareness of environment or situation; focus on irrelevant stimuli such as color of bedspread or room
- noises, people, sensory misperceptions distracts them
- experience illusions, misinterpretations, and hallucinations
Primary and Initial Sign of Delirium
altered level of consciousness that is seldom stable and usually fluctuates throughout the day
Judgment and Insight
- judgment is impaired
- cannot perceive potentially harmful situations or act in their own best interest
- insight depends on severity of delirium
Roles and Relationships
- unlikely to fulfill their roles during course of delirium
- most regain previous level of functioning; no long-standing problems with roles or relationships
Self-Concept
- no direct effect
- often feel frightened or threatened
- those with some awareness may feel helpless or powerless to do anything to change it
- may feel guilt, shame, and humiliation if delirium resulted from substance abuse
Physiological and Self-care Considerations
- experience disturbed sleep-wake cycles; difficulty falling asleep, daytime sleepiness, nighttime agitation, or complete reversal of usual daytime waking/ nighttime sleep pattern
- ignore or fail to perceive internal body cues such as hunger, thirst, or urge to urinate or defacate
Nursing Diagnosis
- risk for injury
- acute confusion
- disturbed sensory perception
- disturbed thought process
- disturbed sleep pattern
- risk for deficient fluid volume
- risk for imbalanced nutrition: less than body requirements
Nursing Interventions
- promoting client’s safety
- managing clients confusion
- controlling environment to reduce sensory overload
- promoting sleep and proper nutrition
Nursing Interventions: Promoting Client Safety
- teach patient to request assistance for activities (getting out of bed, going to the bathroom)
- provide close supervision to ensure safety during these activities
- promptly respond to the patients call for assistance
Nursing Interventions: Managing Clients Confusion
- speak to client in a calm manner in a clear low voice
- use simple sentences
- allow adequate time for the client to comprehend and respond
- allow client to make decisions as much as he/she is able to
- provide orienting verbal cues when talking with the client (facing them, using their name, calendars)
- use supportive touch if appropriate
- correct them matter-of-factly
Nursing Interventions: Controlling Environment to Reduce Sensory Overload
- keep environmental noise to a minimum (television/ radio)
- monitor clients response to visitors; explain to family and friends that the client may need to visit quietly one at a time
- validate the clients anxiety and fear, but do not reinforce misperceptions
ex: “I know things are upsetting and confusing right now, but your confusion should clear as you get better”
Nursing Interventions: Promoting Sleep and Proper Nutrition
- monitor sleep and elimination pattern
- monitor food and fluid intake; provide prompts or assistance to eat and drink adequate amounts of food and fluids; may be helpful to sit with the patient at meals
- provide periodic assistance to the bathroom if client does not make requests
- discourage daytime napping to help sleep at night
- encourage some exercise during the day, such as sitting in a chair, walking in the hall, or activities the client can manage
Client and Family Education
- monitor chronic health conditions carefully
- visit physician regularly
- tell health care providers what medications are taking, OTC, dietary supplements, and herbal preparations
- check with physician before taking nonprescription meds
- avoid alcohol and recreational drugs
- get adequate sleep
- use safety precautions when working with paint solvent, insecticides, and similar products
Community Based Care
- medical evaluation–> can confirm dementia and appropriate treatment and care plan can be initiated if cognitive function is impaired after delirium
- initiate referrals to home health aide, visiting nurse, or rehab if continue to experience cognitive problems
- support groups
