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Nursing 172 > Delirium > Flashcards

Delirium Flashcards

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1
Q

Cognition

A

brains ability to process, retain, and use information

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2
Q

Cognitive Abilities

A

reasoning, judgment, perception, attention, comprehension, and memory
-essential for making decisions, solving problems, interpreting the environment, and learning new information

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3
Q

Cognitive Disorder

A

disruption or impairment in these higher level functions of the brain
-disruption of cognitive abilities

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4
Q

Delirium

A

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
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5
Q

Examples of Illusion

A

an electrical cord on the ground may appear to them as a snake

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6
Q

Example of Misinterpretation

A

may mistake the banging of a laundry cart in the hallway for a gunshot

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7
Q

Example of Hallucination

A

may see “angels” hovering above them when nothing is there

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8
Q

Onset of Delirium

A

rapid

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9
Q

Duration of Delirium

A

brief

-1 week; rarely more than 1 month

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10
Q

Delirium: State of Awareness

A
  • impaired

- fluctuates from heightened awareness to environmental stimuli, vivid dreams, and nightmares

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11
Q

Delirium: Memory

A

-short-term memory impaired

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12
Q

Delirium: Speech

A

may be slurred, rambling, pressured, or irrelevant

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13
Q

Delirium: Thought Process

A

temporarily disorganized

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14
Q

Delirium: Perception

A

visual or tactile hallucinations

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15
Q

Delirium: Emotions

A

anxious, irritable, crying, apathy (lack of interest)

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16
Q

Delirium: Psychomotor Activity

A

agitated, restless, hyperactive, striking out

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17
Q

Predisposing Factors ( at risk of developing a problem)

A
  • 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
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18
Q

Etiology

A

almost always results from an identifiable physiological, metabolic, or cerebral disturbance or disease from drug intoxication or withdrawal

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19
Q

Risk Factors

A
  • increased severity of physical illness
  • older age
  • hearing impairment
  • decreased food and fluid intake
  • medications
  • baseline cognitive impairment such as that seen in dementia
20
Q

Causes of Delirium: Physiological or Metabolic

A
  • 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
21
Q

Causes of Delirium

A

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
22
Q

Cause of Delirium: Infection

A
  • Systemic: sepsis, urinary tract infection, pneumonia

- Cerebral: meningitis, encephalitis, HIV, syphilis

23
Q

Cause of Delirium: Drug Related

A
  • Intoxication: anti-cholinergic, lithium, alcohol, sedatives, and hypnotics
  • Withdrawal: alcohol, sedatives, and hypnotics
  • reactions to anesthesia, prescription medication or illicit (street) drugs
24
Q

Treatment and Prognosis

A
  • 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
25
Q

Psychopharmacology

A
  • 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
26
Q

Haloperidol

A
  • 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
27
Q

Other Medical Treatment

A
  • 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
28
Q

Application of The Nursing Process Focuses On?

A

meeting physiological and psychological needs

29
Q

Nursing Process: History

A
  • thorough history of medical illness, alcohol, or other drugs
  • may need to gather from family if ability to provide accurate data is impaired
30
Q

General Appearance and Motor Behavior

A
  • 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
31
Q

Mood and Affect

A
  • 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
32
Q

Thought Processes and Content

A
  • 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
33
Q

Sensorium and Intellectual Processes

A
  • 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
34
Q

Primary and Initial Sign of Delirium

A

altered level of consciousness that is seldom stable and usually fluctuates throughout the day

35
Q

Judgment and Insight

A
  • judgment is impaired
  • cannot perceive potentially harmful situations or act in their own best interest
  • insight depends on severity of delirium
36
Q

Roles and Relationships

A
  • unlikely to fulfill their roles during course of delirium

- most regain previous level of functioning; no long-standing problems with roles or relationships

37
Q

Self-Concept

A
  • 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
38
Q

Physiological and Self-care Considerations

A
  • 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
39
Q

Nursing Diagnosis

A
  • 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
40
Q

Nursing Interventions

A
  • promoting client’s safety
  • managing clients confusion
  • controlling environment to reduce sensory overload
  • promoting sleep and proper nutrition
41
Q

Nursing Interventions: Promoting Client Safety

A
  • 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
42
Q

Nursing Interventions: Managing Clients Confusion

A
  • 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
43
Q

Nursing Interventions: Controlling Environment to Reduce Sensory Overload

A
  • 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”
44
Q

Nursing Interventions: Promoting Sleep and Proper Nutrition

A
  • 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
45
Q

Client and Family Education

A
  • 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
46
Q

Community Based Care

A
  • 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

Nursing 172 (120 decks)

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