Delirium
Submitted by Danielle Lewis, CHUC, of
Learning objectives:
1. Describe two causes and two effects of delirium.
2. List two diagnostic tests that might be ordered for
patients with delirium.
3. Explain how health unit coordinators can assist nursing
staff caring for patients with delirium.
While paging the on-call cardiologist, Katie, a certified health
unit coordinator, hears a call for help from a patient’s room. Upon answering
the call light, the visitor in the room tells Katie that Mrs. Smith, a
post-operative patient, is struggling to get out of bed and that she has pulled
out her IV and is screaming that she has to go home.
Mrs. Smith may be suffering from Delirium. Delirium, as
defined by The American Psychiatric Press Textbook of Psychiatry, is “a
transient, usually reversible dysfunction in the cerebral nervous system that
has an acute or sub-acute onset and is manifested clinically by a wide array of
neuropsychiatric abnormalities.”
Delirium is not to be confused with dementia. Dementia
occurs over a period of months or years and affects a person’s intellectual
capabilities. A person with dementia can suffer memory loss, have difficulty
expressing thoughts and is generally in an attentive, conscious state.
Delirium has a sudden onset of symptoms. It can manifest
over a few days or in just a few hours. Delirium alters a patient’s mental
status. The person may seem inattentive and unable to focus. They can become
disoriented and agitated and may even hallucinate.
Emotional changes such as anger, irritation, depression,
apathy and euphoria are other symptoms of delirium. Physical changes can include
short term memory problems, altered sleep patterns and alternating between
lethargy and hyperactivity to name a few.
Delirium is believed to stem from imbalances in the brain’s
neurotransmitters. New drugs alone, or their interaction with other drugs, can
create or worsen these chemical imbalances. Dehydration, which can alter
electrolytes, can also be a contributing factor.
Withdrawal from drugs or alcohol can also cause delirium.
Other causes include: surgery, severe illnesses such as respiratory and urinary
tract infections, heart attacks, hypoxia, hypercapnia, kidney failure, heart
failure and chronic pulmonary disease. Post-operative, elderly and burn
patients as well as patients with pre-existing mental disorders have a greater
risk of developing delirium.
The onset of delirium can create a whole new set of problems
for the patient in addition to the condition for which they were admitted. It
can cause complications that may increase the length of their hospital stay,
the chance that they will need to go to a long-term care facility and can even
increase the chance of death.
To determine a patient’s mental function, the doctor or
nurse would ask the patient standard questions. They might ask the patient to
name the days of the week in reverse, to add or subtract a series of numbers or
to repeat a series of words.
If suspecting delirium, a doctor may order several blood tests
in addition to the mental function evaluation. Some blood test examples include:
ammonia level, a comprehensive metabolic panel, blood gases, drug and alcohol
levels, magnesium and B-vitamin levels. The patient might also be sent for a
chest x-ray to evaluate for pneumonia or for a CT scan or MRI to rule out a
stroke as the cause of the symptoms.
Doctors will treat the underlying medical cause of the
delirium as well as adding and/or removing certain medications from a patient’s
regimen. Some drugs known to cause delirium symptoms include: narcotics,
Cimetidine, Lidocaine, anticholinergics and central nervous system depressants.
One-third of older patients seen in the emergency department
suffer from delirium. One-third of patients admitted to the hospital experience
delirium. The occurrence of delirium during a patient’s hospital stay is quite
common. According to one study, up to 80 percent of ICU patients suffer from
delirium.
Certain steps can be taken to prevent or alleviate the
symptoms of delirium. Making sure the patient can see and hear clearly can help
avoid confusion. Nurses, as well as health unit coordinators, should make every
effort to be sure a patient’s eyeglasses and hearing aids travel with the
patient.
The heath unit coordinator can procure devices to assist
vision or hearing-impaired patients. There are large-numbered telephones, sound
amplifiers and even posters to which a patient can point to certain words or
phrases to express his or herself clearly.
Helping to keep patients oriented to time and place can also
help. The patient’s room should have a window and a clock so they can be more
aware of what time of day it is. This can prevent the “sundowner” effect, where
patients confuse night and day.
Seeing a loved one in a state of confusion or agitation can
be upsetting for family members. Although it is helpful to have a calm, caring
family member at the bedside to offer reassurance and familiarity to the
patient, sometimes anxious or overzealous visitors can worsen the patient’s
anxiety.
The health unit coordinator can assist the nurses by
screening telephone calls or turning off the telephone ringer in the patient’s
room and also by limiting the number of visitors allowed to enter the patient’s
room.
References:
The Journal of the American Medical Association, JAMA
Patient Page, Jama April, 14, 2004, Vol 291, No 14
Critical Care Nurse/Supplement Feb 2007
Textbook of Psychiatry, The American Psychiatric Press,
copyright 1999, p 317-332
American Geriatric Society, Foundation for Health in Aging,http:/www.healthinaging.org
Http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001749/
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Subject: Delirium
Submitted by:
Danielle Lewis, CHUC, of
Objective: To identify facts about Delirium
Resources:
Accompanying article submitted by Danielle Lewis, CHUC
Instructions: After reading the article, please circle the best
answer.
1. Delirium is best described as:
a. digestive disorder
b. a cerebral nervous system dysfunction
c. a blood disorder
d. an immune disorder
2. Which is NOT a symptom of delirium?
a. inability to focus
b. blindness
c. confusion
d. depression
3. What percentage of ICU patients suffer from delirium?
a. 50%
b. 60%
c. 70%
d. 80%
4. Which medication is known to cause confusion?
a. antibiotics
b. narcotics
c. anticoagulants
d. potassium infusion
5. Which of the following blood tests would likely not be ordered to diagnose the cause of
delirium?
a. drug and alcohol
b. ammonia
c. magnesium
d. CEA
6. What would the health unit coordinator not do to assist in the care of the
patient suffering from delirium?
a. screen incoming telephone calls
b. turn telephone ringer in room off
c. limit the number of visitors
d. encourage the patient to push fluids
7. Which item(s) help keep patients from becoming
disoriented?
a. Internet access
b. clock and windows
c. daytime soap operas
d. a copy of their medical chart
8. A patient with a delirium diagnosis is hard of hearing.
The health unit coordinator should:
a. send hearing aids home with a family member
b. shout loudly at the patient
c. make sure the patient’s hearing aid is always available
d. throw hearing aids away since the insurance company will
replace them
9. Dehydration can cause delirium because it alters:
a. blood sugar
b. electrolytes
c. white blood cell count
d. liver function
10. What might a doctor or nurse ask a patient to evaluate
mental function?
a. to name all 50 states
b. to perform Calculus
c. to repeat a series of words
d. to speak a foreign language