Unit 5 - Assessing Delirium

Question 1

How can we recognize changes in cognition for delirium when doing our routine assessments? (3)

Answer 1

• know patient’s baseline
• assess for deviations from that baseline
• If there are deviations, CAM

Question 2

Delirium is indicated in the presence of 1, 2, and either 3 and 4. Name them.

Answer 2

1. Acute onset or fluctuating course
2. Inattention (easily distracted, difficulty focusing)
3. Disorganized thinking (incoherent, illogical)
4. Altered LOC (alert, vigilant, lethargic, stupor, or coma)

Question 3

What assessment method do we use to assess delirium?

Answer 3

Confusion assessment method (CAm)

Question 4

What does CAM measure? (4)

Answer 4

• evidence of acute change in cognition +
• difficulty focusing attention or keeping track of what is being said

and either one of:
- patient’s displays disorganized thinking through their actions or conversation. Their convo is difficult to understand (incoherent)
- lethargic, hyperalert, or difficulty to arouse

Question 5

How many times should delirium be assessed?

Answer 5

• every 24 hours by RNAO

Question 6

What are actions to monitor if you think there is possible delirium? (2)

Answer 6

• Consult medical practitioner
• monitor for physiological stability: oxygen sat, bloodwork, hydration, vision, hearing, and pain

Question 7

What are actions to be done in recognizing and preventing delirium if you think there is a possible case? (5)

Answer 7

1. Make sure environment is optimized
   - consider lighting, noise, and sleep
2. Ensure safe environment
   - reduce risk of falls
3. Enhance therapeutic communication and emotional support
4. Education of older adults, staff, and family
5. Ongoing monitoring using screening assessment questions and tools

Question 8

What are ways to treat the underlying cause of delirium? (4)

Answer 8

• antibiotics for infections
• keep oxygenated
• keep safe and comfortable
• correct electrolyte imbalances

Question 9

Good nursing care is an intervention to prevent and respond to delirium. How so? (7)

Answer 9

• calm and reassuring
• fall risk reduction program
• offering herbal tea or warm mild rather than med sleep aids
• assessing and managing pain
• encourage mobilization
• correcting hearing and vision deficits
• active engagement of family