Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing Care of the Older Person > Module 4 - Delirium > Flashcards

Module 4 - Delirium Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

what is delirium?

A

a common and serious medical condition characterised as an acute state of confusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

which age group is delirium most common in? why is this?

A

most common in older people due to their increased risk factors and comorbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

older people with delirium are more likely to experience what sort of outcome?

A

an adverse one. more likely to be admitted permanently to a residential facility, to stay in hospital longer and experience iatrogenic complications, even more likely to die

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

two types of delirium

A

hypoactive and hyperactive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

decreased physical activity, withdrawal, lethargy

A

hypoactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

decreased speed and amount of speech, staring, listlessness

A

hypoactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

drowsiness and reduced awareness of surroundings

A

hypoactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

increased physical activity, hyper arousal, hyper alterness

A

hyperactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

hallucinations, delusions and agitation

A

hyperactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

rambling speech and restlessness

A

hyperactive delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

onset of delirium

A

quickly, in days or hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

how long can delirium last for?

A

up to a month

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what can make delirium difficult to catch on to?

A

it fluctuates throughout the day, and behaviours can change quickly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

delirium can cause deterioration of what?

A

the memory

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

risk factors - demographic

A

over 65yrs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

risk factors - cognitive state

A

prior episode of delirium, dementia or depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

risk factors - comorbidities

A

acute or chronic medical condition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

risk factors - sensory impairment

A

visual or hearing loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

risk factors - surgery

A

procedure requiring general anaesthetic or sedation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

risk factors - medications

A

polypharmacy, withdrawal from drugs or alcohol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

risk factors - hospital related (iatrogenic)

A

overstimulation/understimulation, ICU admission, multiple ward changes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

decreased sensation of thirst and chewing strength and taste can result in what?

A

dehydration and malnutrition, both which are risk factors for delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

musculoskeletal degeneration and disturbed sleep patterns can result in what?

A

pain and mobility issues, lack of sleep > both which are risk factors for delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

ineffective drug metabolism and suppressed immune response can result in what?

A

build up of toxins and hidden signs of infection > both which are risk factors for delirium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

3 nursing interventions for delirium

A
  • physical and verbal orientation cues
  • assessing and treating pain regularly
  • collaboration with multidisciplinary team
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

3 more nursing interventions for delirium

A
  • supporting and educating family and friends
  • assisting the person with eating and drinking
  • managing surrounds (sound and lighting)
27
Q

prolonged delirium can cause

A

a dementia process to develop in the brain

28
Q

in older people, delirium may be the only sign of what?

A

an underlying acute medical condition

29
Q

does a dementia diagnosis guarantee delirum?

A

no

30
Q

the first step to recognising delirium is noticing what?

A

behavioural changes

31
Q

2 most commonly use assessment tools for delirium

A
  • confusion assessment tool (CAM)

- the 4AT

32
Q

the recognition of delirium by CAM requires the presence of…

A

feature 1 and 2 AND either 3 or 4

33
Q

feature 1 of CAM

A

acute onset and fluctuating course

34
Q

acute onset and fluctuating course

A
  • is there evidence of an acute change in mental status from the person’s usual state?
  • does the behaviour fluctuate during the day, coming and going or decrease/increase in severity?
35
Q

feature 2 of CAM

A

inattention

36
Q

inattention

A

does the person have difficulty focusing their attention? are they easily distracted or having trouble keeping track of what is being said?

37
Q

feature 3 of CAM

A

disorganised thinking

38
Q

disorganised thinking

A

is the person’s thinking disorganised or incoherent? are they rambling? switching from subject to subject or showing an illogical flow of ideas?

39
Q

feature 4 of CAM

A

altered level of consciousness

40
Q

altered level of consciousness

A

any response other than ‘alert’ to rating consciousness

  • alert: normal
  • vigilant; hyper alert
  • lethargic; drowsy, easily roused
  • stupor; difficult to rouse
  • coma; unrousable
41
Q

the 4AT

A

score of 4 or more indicates delirium

42
Q

causes of delirium - D

A

drugs; newly introduced ones, dosage changes or polypharmacy

43
Q

causes of delirium - E

A

electrolyte abnormalities and pain

44
Q

causes of delirium - L

A

lack of drugs; withdrawal from alcohol, nicotine, benzodiazepines

45
Q

causes of delirium - I

A

infection; UTI, respiratory infections

46
Q

causes of delirium - R

A

reduced sensory input; hearing/visual impairment, darkness, change in environment

47
Q

causes of delirium - I (second one)

A

intracranial problems; stroke, meningitis, seizures, dementia

48
Q

causes of delirium - U

A

urinary retention, constipation

49
Q

causes of delirium - M

A

myocardial problems; myocardial infarction, heart failure and arrhythmia

50
Q

what are the 5 P’s of delirium?

A

pee, poo, pain, pus, pills

51
Q

PEE

A

UTIs, dehydration (leading to decreased urinary output), urinary retention, indewlling catheter insertion

52
Q

POO

A

constipation and diarrhoea

53
Q

PUS

A

infection of any kind can cause delirium

54
Q

PAIN

A

unidentified/unmanaged pain can also cause delirium

55
Q

PILLS

A

interactions and adverse effects of medications can bring on delirium

56
Q

environment for those with hyperactive delirium

A

too much noise or overstimulation can induce/worse the symptoms. often need single room or quieter environment to foster recovery

57
Q

in investigating delirium, what information should be gathered when obtaining the person’s history? (4 things)

A
  • full head to toe assessment
  • set of vitals
  • identify recent medication changes
  • identify any comorbidities
58
Q

4 investigations used to screen for causes of delirium

A
  • urinalysis, MSU
  • blood tests
  • chest x-ray
  • electrocardiogram (ECG)
59
Q

blood test to determine cause for delirium should test for?

A
  • kidney function
  • electrolytes
  • glucose
  • calcium
  • liver function
  • cardiac enzymes
  • B12
  • folate
  • thyroid function
60
Q

if a fever or cough is present (shown by chest x-ray or in chest ausculation), what order may be made?

A

blood or sputum cultures

61
Q

if pt is SOB, has a cough, or pathology has detected anything abnormal in the chest, what order may be made?

A

arterial blood gases (ABGs)

62
Q

if pt has a history of falls, is on anticoagulants, or has neurological signs present, what test may be ordered?

A

CT brain scane

63
Q

if headache, fever and meningism are present, what may be ordered?

A

lumbar puncture

64
Q

what test may assist in determining differential diagnosis such as a non-convulsive status epilepticus?

A

electroencephalogram (EEG)

Nursing Care of the Older Person (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions