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NSO424 Introduction to nursing assessment skills > Delirium, sepsis > Flashcards

Delirium, sepsis Flashcards

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1
Q

what is delirium?

A

Delirium is a serious medical emergency and defined as a state of mental confusion or acute confusional state.

  • A syndrome manifesting as an acute change in mental status that is characterised by inattention and disturbance in cognition that develops over a short period of time with a fluctuating course of symptoms.
  • Medical emergency. Acute onset.
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2
Q

what are statistics of people that have delirium? relation to dementia>

A
  • Can be difficult to distinguish dementia from delirium. Some may have both. If clinical uncertainty exists over the diagnosis, the person should be managed initially for delirium.
  • 10% of nursing home residents have it
  • 20% of people in hospital have it
  • Associated with a 35-40% risk of death after it first presents
  • 50% of over 65s in hospital will have had delirium at some stage
  • Individuals who develop delirium are more likely to stay in hospital for longer, have dementia at a 3 year follow up, have more complications and require long term care.
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3
Q

Who is delirium most common to?

A

-More common in people with poor eyesight, poor hearing, dementia, constipation, patients who are frail, prescribed multiple medications, have pain, injury, infection etc

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4
Q

what is the difference between dementia and delirium?

A

Think: OCD CAMPS
Delirium VS Dementia
Rapid- hours to days [ ONSET] Insidious- months (+)

Fluctuating- “sundown” [COURSE] Progressive

Reversible- days- week [DURATION] Irreversible

Altered [CONSCIOUSNESS] often normal
signific inattention and no conc [ATTENTION] often normal
Immediate recall impaired [MEMORY] often normal

Hyper/hypoactive [PSYCHO MOTOR CHANGES] none

often reversed [SLEEP WAKE CYCLE] often normal

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5
Q

what is hypoactive delirium?

A

= reduced appetite, paucity of speech, with or without prompting, withdrawn, quiet and sleepy. Least likely to be detected by clinicians. It is also less studied, which effectively means there is less good quality evidence with regard to outcomes.

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6
Q

Hyperactive delirum?

A

= heightened arousal, restless, agitated and aggressive.

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7
Q

why is hypoactive delirium underdetected?

A

Because the patients do not present a management challenge. Often people will document ‘quiet day’ in the notes.

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8
Q

why is hyperactive delirium often detected quickly?

A

Because these patients are often more challenging and moving round the ward presenting a risk to themselves and others.

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9
Q

what are the symptoms of delirium?

A
  • Fluctuation
  • change in mood
  • change in alertness
  • agitation
  • drowsiness
  • hallucinations
  • delusions
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10
Q

what are the risk factors for delirium?

A
  • infection
  • multiple medicines
  • changed environment
  • dehydration
  • surgery
  • constipation
  • pain
  • hearing impairment
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11
Q

what are the pre-disposing factors for delirium?

A
  • Age- increases the risk
  • Dementia or pre-existing cognitive impairment
  • History of delirium
  • People with dementia
  • TIA’s or stroke
  • Functional or sensory impairment
  • Comorbidity or severity of illness
  • Depression
  • alcohol abuse
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12
Q

what are the precipitating factors for delirum?

A
  • Major surgery (i.e hip surgery)
  • Trauma or urgent admission to hospital
  • Infecton
  • Coma
  • Polypharmacy
  • Use of psychoactive or sedative-hypnotic drugs
  • Any iatrogenic event
  • Use of physical restraints
  • Bladder catheterisation
  • Physiological and metabolic abnormalities e.g high blood-urea nitrogen: creatinine ratio, abnormal sodium, glucose or potassium concentrations in serum hypoxaemia or metabolic acidosis.
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13
Q

assessment tools for delirium: 4AT

outline and give examples of what it can be used with?

A

-4AT
This a validated 2-minute tool for delirium detection.
Designed to help quickly and easily detect delirium in routine clinical practise.
No special training required.
All patients can be assessed, including those unable to speak (e.g with severe drowsiness)
Incorporates the Months Backwards test and the Abbreviated Mental test- 4 (AMT4), which are short tests for cognitive impairment.

Can be combined with single monitoring tool like the Single Question in Delirium (SQiD) or the NEWS2.

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14
Q

what are the 4 sections for 4AT?

A

Alertness: (high=4),
4 cognitive based question: age, DOB, location and current year.
(score 1= 1 wrong, 2+=2),
Attention: recite months of year backwards
(score 0.1 or 2),
Acute change of fluctuating course
Has there be an acute change in the person’s awareness, cognition or mental function which can include things like hallucinations, paranoia that’s been arising within the last 2 weeks, but is still evident the last 24hours.
This is hard to assess, because difficult to see if a person has a baseline cognitive impairment such as dementia.
Ideally, need collateral information from the family etc.
“Fluctuating” cognitive means to be coherent at one point and then not another. Score of 4 is given if patient has acute// fluctuating awareness etc.
If overall score is 4 or above= high chance for delirium then need to alert medical team.
1-3 at AMT= could be underlying cognitive impairment. May lead to referral to memory team for possible dementia etc

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15
Q

methods for measuring delirium: CAM

WHAT IS THIS ?

A
  • Designed to allow non-psychiatric clinicians (with training ofc) to diagnose delirium quickly and accurately post formal cognitive testing.
  • CAM diagnostic algorithm based on 4 cardinal features if delirium: 1) acute onset and fluctuating course, 2) inattention, 3) disorganized thinking, and 4)altered level of consciousness. A diagnosis according to the CAM requires the presence of features 1,2 and either 3 or 4.
  • In critical care/recovery room after surgery, CAM-ICU should be used.
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16
Q

tools for detecting delirium: SQID

What is this?

A
  • A single prompt question that asks the patient’s friend/relative: “Is (person) more confused than before?”
  • Asking regularly can identify changes in a patient’s condition, which could then possibly indicate delirium (remember: acute confusional state).
17
Q

Delirium can also be present as an interplay of multiple components.
PINCH ME can identify potential underlying causes. What does this stand for?

A

Pain, Infection, Constipation, Hydration, Medication, Environment

18
Q

what are the general principles for preventing delirium?

A
  • Request reviews when multiple medications are being taken
  • Check on admission and then daily for changes in behaviours that might indicate delirium
  • Avoid unnecessary movement. Try and keep their surroundings the same i.e. avoid moving people within and between wards or rooms unless necessary
  • Make sure that carers (i.e. health care professionals, family) have support
  • Create environments with appropriate levels of stimulation
  • Focused history taking and examination which includes monitoring vital observations.
19
Q

prevention and management of delirum can be achieved by reducing what 7 factors and how?

A
  • Mobility= encourage movements, provide support and guidance on exercise if mobility is restricted i.e. chair exercises
  • Nutrition/dietary intake= ensure dentures are clean/fitted/worn, refer to NICE nutrition guidelines, complete dietary charts if required
  • Sleep= where possible try and reduce sleep disturbance/ routine
  • Infection= look for signs, avoid clinical intervention where possible which can cause infections i.e. IV cannula insertion

-Fluids= encourage drink to reduce dehydration and constipation, fluid balance
charts help track fluid intake

  • Orientate= talk to individuals to help orientate, ensure glasses and hearing aids function and are worn correctly, make clocks/calendars available, ensure wrooms well-lit.
  • Pain management= look for signs of pain, assess for pain (pain tools) and manage/control pain (e.g. antiemetics, mindfulness etc)
20
Q

what is the NICE guidelines regarding capacity and consent in individuals with delirium?

A
  • Informed consent is v important HOWEVER, if the individual gradually loses capacity, healthcare professionals (unless specifically told not to) have the duty to talk to family/carers.
  • Urgent interventions needs to prevents serious deterioration etc ALL in the interest of the patient’s safety.
  • Most agree that if medical colleagues would deem a treatment appropriate, and reasonable people would want the treatment themselves, then if can be given IF urgently necessary.
  • Should follow the Department of Health’s advice on consent and the code of practise for the Mental Capacity Act (NICE, 2010).
21
Q

what procedures are put into place to treat delirium?

A
  • Must identify and manage the potential underlying cause/ combination of causes.
  • Ensure effective communication between patient to family. Professionals etc.
  • Use of verbal/non-verbal techniques or de-escalate the situations if patients are distressed.
  • Involve family and friends= ask if can identify specific day etc where behaviour of patient changed
  • Provide a suitable care environment
  • If patient is distressed/ considered a risk to themselves AND communication techniques as outlined above are not effective, then might pharmacological intervention.

-Drug treatment of delirium should only eb used when ESSENTIAL. Onset of action is usually rapid.
Haloperidol is often used because if has few anticholinergic side effects, minimal cardiovascular side effects and no active metabolites.

-Benzodiazepines usually preferred when delirium is associated with withdrawal from alcohol or sedatives.

  • For people whose delirium doesn’t improve:
    • re-evaluate for underlying causes
    • follow up and assess for possible dementia
22
Q

Many patients still have residual symptoms on discharge so need certain interventions. This includes?

A
  • Continued vigilance about medication, environmental change and sensory problems during discharge planning and aftercare
  • Cognitive testing shouldn’t be carried out in the 12 weeks post delirium, if it then it should contribute to a diagnosis of dementia as its likely to be influenced negatively by the delirium.
  • Close liaison between hospital and primary acre settings is an essential part of discharge planning.
  • Patients or their families h=should be reassured that an episode of delirium is not the start of an inevitable progression to dementia and that can expect a full recovery.

-Delirious patients placed in long term care for delirium may be wrongfully identified as having dementia. Decisions to place patients in care should be made only after having an adequate assessment that differentiates between dementia and delirium.

23
Q

what is sepsis?

what are the statistics for sepsis? rough estimation for people in ENG treated, and how mnay die from s

A

A Medical emergency and a time-critical condition.
 Sepsis is when your immune systems overreacts
as response to an infection.
Sepsis is sometimes called blood poisoning or
septicaemia.
 Sepsis can lead to multiple organ failure.
Sepsis and severe infection are one of the most
common reasons for admission to hospital, and
the most common cause of inpatient deterioration.
 Assessing and early detection for sepsis is of
clinical importance.
Anyone with an infection can get sepsis.

 for the year 2017/18, hospitals in England treated
200,000 episodes of sepsis-
 Across the UK, sepsis claims as many as 52,000
lives per year

24
Q

what is the SEPSIS pneumonic for suspecting Sepsis?

A

Slurred speech

Extremely cold hands and feet

Passing no urine in 24 hrs and racing heart palpitations

Severe breathlessness

It feels like you’re going to die

Shivering and muscle pain

25
Q

what are the different methods for assessing for sepsis?

Is assessing for sepsis easy?

A

Sepsis can be challenging to identify – as clinical
presentation is variable between patients and
underlying cause.

• NEWS2
Vital observations (BP, CRT, HRT, RR, Sp02, Temp)
• ABCDE
Think, AVPU, BM, urine output, possible sources of
infection.

26
Q

what are the SEPSIS bundle six?

A

• Administer high flow oxygen: aim
to keep saturations > 94% (88-
92% if at risk of CO2 retention
e.g. COPD).

• Take blood cultures: At least a
peripheral set. Consider e.g. CSF,
urine, sputum. Think source
control! urinalysis for all adults.

• Give IV antibiotics According to
Trust protocol.

Give IV fluids.

Check serial lactates -
levels>2 mmol/L indicate
sepsis.

 Measure urine output -
May require urinary
catheter. Ensure fluid
balance chart commenced
& completed hourly.
27
Q

What is the SOFA score? What does it evaluate?

What is the qSOFA?

A

SOFA= Sequential Organ Failure Assessment Score
Indicates severity of organ failure

Evaluates:
Respiration, coagulation, cardiovascular, CNS, liver function and renal

qSOFA= quick sofa score
Simple beside criteria to quickly identify adult patients with suspected infection
-RR >or equal to 22 breaths/min
-Altered mental status
-SBP < or equal to 100 mmHg

NSO424 Introduction to nursing assessment skills (10 decks)

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