Need Help Stat

CONSIDER: DELIRIUM

DEFINITION

Delirium: A disturbance in consciousness with reduced ability to focus, sustain, or shift attention; a change in cognition or the development of a perceptual disturbance that develops over a short period of time and tend to fluctuate during the course of the day (American Psychiatric Association, 2000).

Acute change in mental status that is characterized by a sudden onset of impaired attention, disorganized thinking, or incoherent speech. The patient usually has clouded consciousnesses, perceptual disturbances, sleep-wake problems, psychomotor agitation or lethargy, and is disoriented (Flaherty, J., 1998).

ASSESSMENT/SCREENING/DIAGNOSIS

Assessment Screening Questions

Assess patient's baseline mental status.

  • Ask family members, friends, neighbors.
  • If admitted from another setting:
    • Check for baseline on transfer form.
    • Call and speak to the staff re-baseline.

Atypical Presentation: Elderly may present with change in function or level of consciousness, confusion, falls, or agitation rather than typical signs of illness when an underlying acute problem is present.

For patients not in an acute care facility: If source of delirium cannot be quickly identified and treated and/or if the patient is rapidly declining in health and/or function related to the delirium-Transfer patient to acute care facility.

It is not unusual for patients with dementia to also be delirious. Agitation thus may be a manifestation of dementia alone, or it may be caused or made worse by delirium.

Most Likely Causes of Delirium by Etiologic Agent: Assessment & Interventions
Etiologic Agent Physical Findings Nursing Actions
Hypoxia
  • Tachypnea
  • Cyanosis (peripheral & central)
  • Agitation
  • Increased depth of respirations
  • Decreased pO2
  • Accessory muscle use
  • Paradoxical breathing pattern
    		•
  • Determine source of hypoxia, e.g., infection, COPD, PE, bronchospasm, anemia
  • Position patient to facilitate air exchange, e.g., high Fowler's as tolerated by patient
  • Restrict/pace activity to reduce additional oxygen requirements
  • Monitor blood gas results or that of pulse oximetry
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Prepare for oxygen administration, use long tubing to maintain mobilization
  • Document actions and patient response in hospital record
    		•
    Infection

    MOST COMMON:

  • Urinary tract
  • Respiratory
  • Cellulitis


    • MOST OVERLOOKED:

  • Mouth
  • Feet
    		•  Note: Older adults may have infection without fever or elevated WBC.

    Urinary:

    • Dysuria is frequently absent
    • Frequency
    • Urgency
    • Nocturia
    • Incontinence
    • Anorexia
    • Cultures may be negative
    • Protein and/or blood dipstick

    Respiratory:

    • Chills, fever, and elevated WBC (may be absent)
    • Cough may be dry, productive, or absent
    • Slight cyanosis
    • Anorexia
    • Nausea
    • Vomiting
    • Tachycardia/tachypnea
    • Cultures may be negative
    • Breath sounds: wheezes, crackles, or rhonchi possible
    • Change in patient's functional level often seen as first sign of infection in elderly
  • Determine source and site of infection
  • Provide adequate fluids, 2000 ml per day, unless otherwise contraindicated
  • Refer to/notify appropriate advanced practice nurse or house officer
  • Apply cooling techniques as needed and indicated, e.g., remove covers or use cooling mattress/blanket
  • Monitor for flushed hot skin, tachycardia, seizures, changes in body temperature, and breath sounds q 2 h or as indicted by status of the patient
  • Monitor intake and output
  • For respiratory infections provide humidified air, cough and deep breath PRN, provide frequent oral hygiene; chest physiotherapy to mobilize secretions
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Document actions and patient response in hospital record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Dehydration
  • Hypotension with orthostatic changes evident
  • Weakness
  • Nausea
  • Oliguria
  • Dry mucous membranes and skin
  • Poor skin turgor over sternum
  • Lethargy
  • Lightheadedness
  • Elevations in hematocrit, blood urea nitrogen, and creatinine may occur
    		•
  • Determine source of dehydration, e.g., decreased fluid intake or increased fluid output, increased demand (infection)
  • Prepare for fluid replacement and additional diagnostic and therapeutic actions (check BUN, creatinine)
  • Check medications as a cause for increased loss of fluids, e.g., diuretics
  • Check person's ability to swallow or for mechanical problems preventing fluid intake
  • Determine individual's daily fluid needs, and develop a fluid schedule
  • Make sure water is in easy reach of the individual
  • Determine if individual can independently meet fluid needs, if not, place on a fluid schedule
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Continue surveillance of patient q 2-6 hours as indicated by patient status
  • Document actions and patient response in hospital record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Hypernatremia
    (> 146 mEq/L)
  • Weakness
  • Focal neurological deficits
  • Obtundation/Lethargic
  • Elevated HCT, BUN, creatinine, and serum osmolarity, urine sodium
    		•
  • Determine source of hypernatremia, e.g., increased water loss (fever, infection, vomiting, diarrhea), decreased water intake (physical or cognitive limitations), or increased sodium intake
  • Check chemistry panel
  • Prepare for possible fluid replacement
  • Restrict activity to maintain energy balance
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Refer to/notify appropriate advanced practice nurse or house officer
  • Document actions and patient response in record
    		•
    Hyponatremia
    (< 136 mEq/L)
  • Hypotension
  • Hypothermia
  • Nausea
  • Malaise
  • Lethargy
  • Somnolence
  • Decreased serum sodium and osmolality
    		•
  • Determine source of hyponatremia, e.g., inadequate intake of sodium, renal disease, fluid restriction, SIADH, over-diuresis, low sodium tube feedings
  • Prepare for electrolyte and possibly fluid replacement
  • Restrict activity to maintain energy balance
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Document actions and patient response in record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Cognitive impairment
  • Impaired cognitive function(s)
  • Change in mental status exam (See: Try This: Mental Status Assessment of Older Adults: The Mini-Cog)
  • Positive CAM screen (See: Try This - Confusion Assessment Method)
  • Positive CAM-ICU screen (See: Try This - Confusion Assessment Method for the ICU)
    		•
  • Assess for seizure, stroke/TIA, head injury (recent fall). May need head CT.
  • Offer orienting information as a normal part of daily care and activities
  • Work with patient to correctly interpret the environment
  • (See Dementia Topic)
    		•
    Medications    
    Special attention to:
  • New medications
  • Anticholinergic preparations
    -thioridazine
    -amitriptaline
    -neuroleptics
    -tricyclic antidepressants
    -atropine
    -theophylline
    -diphenhydramine
  • histamine-2 blocking agents
    -cimetidine
    -ranitidine
  • analgesics
    -meperidine
    -non-steroidal anti
    -inflammatory agents
    -opiates
  • sedative-hypnotics
    -zolpidem
    -benzodiazepines
  • cardiovascular drugs
    -nifedipine
    -quinidine
    -disopyramide
    -amiodarone
    -beta blockers
  • Corticosteriods
  • Anti-Parkinsonian agents
    		•
  • Variable, depending upon the specific medication, drug-drug interactions, and the person's underlying health problems and health status.
    		•
  • Monitor the effects (intended and adverse) of medications. Be especially vigilant for drug interactions. With the onset of any new symptom, first consider it an adverse reaction to a new medication. (See Medications Topic)
  • Check drug levels as indicated
  • Evaluate each medication; use only those medications indicated by the patient's status, thereby keeping medication to a minimum.
  • Monitor for adverse effects, drug-drug, drug-disease, and drug-nutrient interactions
  • Avoid the use of meperidine, & NSAIDs for more than 2 weeks at a time
  • Use nonpharmacologic sleep enhancing protocols. (See Sleep Topic)
  • Taper or discontinue drugs that cause delirium
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Pain
  • Agitation, restlessness, moaning, grimacing, sighing, body rigidity (especially in dementia)
    		•
  • Assess for pain (See Try This: Assessing Pain & Assessing Pain in Persons with Dementia)
  • Treat and evaluate pain
  • Collaborate with pain team
  • Relieve pain through adequate and appropriate administration of analgesia and alternative nonpharmacologic therapies (See Pain Topic).


    • General Nursing Strategies:

  • Collaborate with interdisciplinary team members.
  • Monitor vital signs, including pain
  • Prevent falls (See Falls Topic)
  • Protect from hazards of immobility
  • Consider companion with patient.
  • Avoid restraints (See Physical Restraint Topic)
    		•

    Reprinted with permission from Springer Publishing Company. Foreman, F.D., Mion, L.C., Trygstad, L., & Fletcher, K. (2003). Delirium: Strategies for Assessing and Treating. In Mezey, M., Fulmer, T., Abraham, I., (Eds.), Zwicker, D. (Managing Ed). Geriatric Nursing Protocols for Best Practice. (2nd edition). New York: Springer Publishing Company.

     

    Last updated - January 2005