Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I –VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
- Assess for risk factors
- Baseline or pre-morbid cognitive impairment
- Medications review
- Pain
- Metabolic disturbances (i.e., hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)
- Dehydration (physical signs/symptoms, intake/output, Na+, blood urea nitrogen/creatinine [BUN/Cr])
- Infection (fever, white blood cells [WBCs] with differential, cultures)
- Environment (sensory overload or deprivation)
- Impaired mobility
- Features of delirium should be assessed every shift (see www.ConsultGeriRN.org for resources for validated instruments)
- Acute onset; evidence of underlying medical condition
- Alertness: Fluctuates from stuporous to hypervigilant
- Attention: Inattentive, easily distractible, and may have difficulty shifting attention from one focus to another; has difficulty keeping track of what is being said
- Orientation: Disoriented to time and place; should not be disoriented to person
- Memory: Inability to recall events of hospitalization and current illness; unable to remember instructions; forgetful of names, events, activities, current news, and so on
- Thinking: Disorganized thinking; rambling, irrelevant, incoherent conversation; unclear or illogical flow of ideas; or unpredictable switching from topic to topic; difficulty in expressing needs and concerns; speech may be garbled
- Perception: Perceptual disturbances such as illusions and visual or auditory hallucinations; and misperceptions such as calling a stranger by a relative's name
- Psychomotor activity: May fluctuate between hypoactive, hyperactive, and mixed subtypes
Nursing Care Strategies
Based on protocols in multi-component delirium prevention studies (Inouye, et al., 1999; Marcantonio et al., 2001 [Level II])
Collaborate with physician/nurse practitioner to treat the underlying pathology and contributing factors. If available, consult with geriatrician and/or Geriatric Nurse Practitioner or Clinical Nurse Specialist.
- Eliminate or minimize risk factors
- Administer medications judiciously; avoid high-risk medications.
- Prevent/promptly and appropriately treat infections.
- Prevent/promptly treat dehydration and electrolyte disturbances.
- Provide adequate pain control.
- Maximize oxygen delivery (supplemental oxygen, blood, and blood pressure [BP] support as needed).
- Use sensory aids as appropriate.
- Regulate bowel/bladder function.
- Provide adequate nutrition.
- Provide a therapeutic environment
- Foster orientation: frequently reassure and reorient patient (unless patient becomes agitated); utilize easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly
- Provide appropriate sensory stimulation: quiet room; adequate light; one task at a time; noise-reduction strategies
- Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation music/tapes; noise-reduction measures; avoid awakening patient
- Foster familiarity: encourage family/friends to stay at bedside; bring familiar objects from home; maintain consistency of caregivers; minimize relocations
- Maximize mobility: avoid restraints and urinary catheters; ambulate or active range of motion three times daily
- Communicate clearly, provide explanations
- Reassure and educate family
- Minimize invasive interventions
- Consider psychotropic medication as a last resort
Follow-up to Monitor Condition
- Decreased delirium to become a measure of quality care
- Incidence of delirium to decrease
- Patient's days with delirium to decrease
- Staff competence in recognition and treatment of acute confusion/delirium
- Documentation of a variety of interventions for acute confusion/delirium
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
