A nurse is caring for a client who has dementia. which of the following interventions

My grandfather has turned 89 years old 2 months ago. He seems to have changed from then on. He always complains of seeing ants in the ceiling, or ants on the floor beside his bed. He sometimes forgets my name. Lately, he keeps on mumbling to himself and looks agitated. He doesnt know where he is anymore, or what the present date is. Im really worried that he is in the early stages of delirium. I think we should have him checked.

• Description
• Statistics and Incidences
• Causes
• Clinical Manifestations
• Assessment and Diagnostic Findings
• Medical Management
  • Pharmacologic Management
• Nursing Management
  • Nursing Assessment
  • Nursing Diagnosis
  • Nursing Care Planning and Goals
  • Nursing Interventions
  • Evaluation
  • Documentation Guidelines
• Practice Quiz: Delirium
• References

Description

Delirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period (DSM-IV-TR).

Statistics and Incidences

Delirium is common in the United States.

• In a systematic review of 42 cohorts in 40 studies, 10-31% of new hospital admissions met the criteria for delirium and the incidence of developing delirium during the admission ranged from 3-29%.
• For patients in intensive care units, the prevalence of delirium may reach as high as 80%.
• Prevalence of postoperative delirium following general surgery is 5-10% and as high as 42% following orthopedic surgery.
• As many as 80% of patients develop delirium death.
• Delirium can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental status.
• In patients who are admitted with delirium, mortality rates are 10-26%.
• Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge.

Causes

The DSM-IV-TR differentiates among the disorders of delirium by their etiology, although they share a common symptom presentation. Categories of delirium include the following:

• Delirium due to a general medical condition. Certain medical conditions, such as systemic infections, metabolic disorders, fluid and electrolyte imbalances, liver or kidney disease, thiamine deficiency, postoperative states, hypertensive encephalopathy, postictal states, and sequelae of head trauma, can cause symptoms of delirium.
• Substance-induced delirium. The symptoms of delirium can be induced by exposure to a toxin or the ingestion of medications, such as anticonvulsants, neuroleptics, anxiolytics, antidepressants, cardiovascular medications, antineoplastics, analgesics, antiasthmatic agents, antihistamines, antiparkinsonian drugs, corticosteroids, and gastrointestinal medications.
• Substance-intoxication delirium. Delirium symptoms can occur in response to taking high doses of cannabis, cocaine, hallucinogens, alcohol, anxiolytics, or narcotics.

• Substance-withdrawal delirium. Reduction or termination of long-term, high dose, use of certain substances, such as alcohol, sedatives, hypnotics, or anxiolytics, can result in withdrawal delirium symptoms.
• Delirium due to multiple etiologies. Symptoms of delirium may be related to more than one general medical condition or to the combined effects of a general medical condition and substance use.

Clinical Manifestations

The following symptoms have been identified with the syndrome of delirium:

• Altered consciousness ranging from hypervigilance to stupor or semicoma.
• Extreme distractibility with difficulty focusing attention.
• Disorientation to time and place.
• Impaired reasoning ability and goal-directed behavior.
• Disturbance in the sleep-wake cycle.
• Emotional instability as manifested by fear, anxiety, depression, irritability, anger, euphoria, or apathy.
• Misperceptions of the environment, including illusions and hallucinations.
• Automatic manifestations, such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure.
• Incoherent speech.
• Impairment of recent memory.

Assessment and Diagnostic Findings

Laboratory tests that may be helpful for diagnosis include the following:

• Complete blood cell count with differential. Helpful to diagnose infection and anemia.
• Electrolytes. To diagnose low or high levels.
• Glucose. To diagnose hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketotic states.
• Renal and liver function tests.  To diagnose renal and liver failure.
• Thyroid function studies. To diagnose hypothyroidism.
• Urine analysis. Used to diagnose urinary tract infection.
• Urine and blood drug screen. Used to diagnose toxicological causes.
• Thiamine and vitamin B12 levels. Used to detect deficiency states of these vitamins.
• Serum marker for delirium. The calcium binding protein S-100 B could be a serum marker for delirium. Higher levels are seen in patients with delirium when compared to patients without delirium.

Medical Management

When delirium is diagnosed or suspected, the underlying causes should be sought and treated.

• Fluid and nutrition. Fluid and nutrition should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake; for the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially thiamine.
• Reorientation techniques. Reorientation techniques or memory cues such as a calendar, clicks, and family photos may be helpful.
• Supportive therapy. The environment should be stable, quiet, and well-lighted; sensory deficits should be corrected, if necessary, with eyeglasses or hearing aids; family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient.

Pharmacologic Management

Delirium that causes injury to the patient or others should be treated with medications.

• Antipsychotics. This class of drugs is the medication of choice in the treatment of psychotic symptoms of delirium.
• Benzodiazepines. Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics.
• Vitamins. Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B12 deficiency, which can cause delirium.
• Hypnotic, miscellaneous. Agents in this class may be useful in the prevention and management of delirium (e.g. melatonin, ramelteon).

Nursing management for a patient with delirium include the following:

Nursing Assessment

Nursing assessment should include:

• Psychiatric interview. The psychiatric interview must contain a description of the clients mental status with a thorough description of behavior, flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgment.
• Serial assessment. Serial assessment of psychiatric status is necessary for determining fluctuating course and acute changes in mental status.

Nursing Diagnosis

NANDA nursing diagnoses for persons with delirium include:

• Disturbed thought processes related to delusional thinking.
• Chronic Confusion related to cognitive impairment.
• Impaired verbal communication related to cognitive impairment.
• Risk for injury related to suicidal ideations, illusions, hallucinations.
• Impaired memory related to cognitive impairment.
• Risk for other-directed violence related to suspiciousness of others.

Nursing Care Planning and Goals

The major nursing care plan goals for delirium are:

• Client will maintain agitation at a manageable level so as not to become violent.
• Client will not harm self or others.

Nursing Interventions

Nursing interventions for patients with delirium include the following:

• Assess level of anxiety. Assess clients level of anxiety and behaviors that indicate the anxiety is increasing; recognizing these behaviors, nurse may be able to intervene before violence occurs.
• Provide an appropriate environment. Maintain a low level of stimuli in clients environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
• Promote patients safety. Remove all potentially dangerous objects from clients environment; in a disoriented, confused state, clients may use objects to harm self or others.
• Ask assistance from others when needed. Have sufficient staff available to execute a physical confrontation, if necessary; assistance may be required from others to provide for physical safety of client or primary nurse or both.
• Stay calm and reassure patient. Maintain a calm manner with the client; attempt to prevent frightening client unnecessarily; Provide continual reassurance and support.
• Interrupt periods of unreality and reorient; client safety is jeopardized during periods of disorientation; correcting misinterpretations of reality enhances clients feelings of self-worth and personal dignity.
• Medicate or restrain patient as prescribed. Use tranquilizing medications and soft restraints, as prescribed by physician, for protection of client and other during periods of elevated anxiety.
• Observe suicide precautions. Sit with client and provide one-to-one observation if assessed to be actively suicidal; client safety is a nursing priority, and one-to-one observation may be necessary to prevent a suicidal attempt.
• Teach relaxation exercises to intervene in times of increasing anxiety.
• Teach prospective caregivers to recognize client behaviors that indicate anxiety is increasing and ways to intervene before violence occurs.

Evaluation

The outcome criteria includes:

• Prospective caregivers are able to verbalize behaviors that indicate an increasing anxiety level and ways they may assist client to manage the anxiety before violence occurs.
• With assistance from caregivers, client is able to control impulse to perform acts of violence against self or others.

Documentation Guidelines

Documentation in a patient with delirium include:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Practice Quiz: Delirium

Nursing practice questions for delirium. Please visit our nursing test bank page for more NCLEX practice questions.

1. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?

A. Its characterized by an acute onset and lasts about 1 month.
B. Its characterized by a slowly evolving onset and lasts about 1 week.
C. Its characterized by a slowly evolving onset and lasts about 1 month.
D. Its characterized by an acute onset and lasts hours to a number of days.

1. Answer: D. Its characterized by an acute onset and lasts hours to a number of days

• D: Delirium has an acute onset and typically can last from several hours to several days.

2. Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimers type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimers disease, the nurse should observe the client for:

A. Occasional irritable outbursts.
B. Impaired communication.
C. Lack of spontaneity.
D. Inability to perform self-care activities.

2. Answer: B. Impaired communication.

• B: Signs of advancement to the middle stage of Alzheimers disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses.
• A and C: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimers disease. During the early stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior.
• D: During the late stage, the client cant perform self-care activities and may become mute.

3. Loretta, a newly admitted client was diagnosed with delirium and has a history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This clients impairment may be related to which of the following conditions?

A. Infection
B. Metabolic acidosis
C. Drug intoxication
D. Hepatic encephalopathy

3. Answer: C. Drug intoxication.

• C: This client was taking several medications that have a propensity for producing delirium; digoxin (a digitalis glycoside), furosemide (a thiazide diuretic), and diazepam (a benzodiazepine).
• A, B, and D: Sufficient supporting data dont exist to suspect the other options as causes.

4. Nurse Ron enters a clients room, the client says, Theyre crawling on my sheets! Get them off my bed! Which of the following assessment is the most accurate?

A. The client is experiencing aphasia.
B. The client is experiencing dysarthria.
C. The client is experiencing a flight of ideas.
D. The client is experiencing visual hallucination.

4. Answer: D. The client is experiencing visual hallucination.

• D: The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception.
• A: Aphasia refers to a communication problem.
• B: Dysarthria is difficulty in speech production.
• C: Flight of ideas is rapid shifting from one topic to another.

5. Which of the following descriptions of a clients experience and behavior can be assessed as an illusion?

A. The client tries to hit the nurse when vital signs must be taken.
B. The client says, I keep hearing a voice telling me to run away.
C. The client becomes anxious whenever the nurse leaves the bedside.
D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.

5. Answer: D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.

• D: Minor memory problems are distinguished from dementia by their minor severity and their lack of significant interference with the clients social or occupational lifestyle.
• A, B, and C: Other options would be included in the history data but dont directly correlate with the clients lifestyle.

References

Sources and references for this study guide for delirium:

• Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,.
• Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.

Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella?

When performing a mental status examination the nurse should include which of the following data?

When should the nurse initiate discharge planning?