Potential 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)
• Positive CAM screen (See: Try This - Confusion Assessment Method)

• 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. Adapted from: 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.