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Posted: November 15th, 2023
Delirium Assessment Skills of Adult Nurses
Delirium is a common and serious condition that affects many hospitalized patients, especially older adults. It is characterized by acute changes in cognition, attention, awareness, and behavior, and it can have negative consequences for patient outcomes and quality of life. Therefore, it is essential that nurses have the skills to recognize and assess delirium in their patients, and to intervene appropriately.
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What is Delirium?
Delirium is a syndrome of disturbed mental function that occurs in response to a stressor, such as infection, surgery, medication, or environmental change. It can affect any patient, but it is more prevalent and severe in older adults, especially those with dementia or other comorbidities. Delirium can manifest in three subtypes: hyperactive, hypoactive, or mixed. Hyperactive delirium is characterized by agitation, restlessness, hallucinations, and delusions. Hypoactive delirium is characterized by lethargy, apathy, reduced responsiveness, and withdrawal. Mixed delirium is a combination of both hyperactive and hypoactive features.
Delirium can have serious implications for patient outcomes and quality of life. It is associated with increased mortality, morbidity, length of stay, hospital costs, risk of falls, functional decline, cognitive impairment, and dementia. It can also cause psychological distress for patients and their families, and increase the workload and stress for nurses and other health care providers.
How to Assess Delirium?
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The first step in assessing delirium is to screen for its presence using a valid and reliable tool. The most widely used screening tool for delirium is the Confusion Assessment Method (CAM), which consists of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. A patient is considered to have delirium if they meet the first two criteria and either the third or the fourth criterion.
The CAM can be administered by nurses in less than five minutes using direct observation and brief cognitive tests. However, the CAM has some limitations, such as low sensitivity for hypoactive delirium, difficulty in distinguishing delirium from dementia or depression, and dependence on the nurse's subjective judgment. Therefore, it is recommended that nurses use the CAM in conjunction with other tools and sources of information, such as medical records, family reports, laboratory tests, and physical examination.
Another tool that can be used to assess delirium is the 4 A's Test (4AT), which consists of four items: alertness, AMT4 (a short test of memory), attention (using the months backwards test), and acute change or fluctuating course. The 4AT has been shown to have high sensitivity and specificity for detecting delirium in various settings and populations. It can be administered by nurses in less than two minutes without any training or equipment. However, the 4AT has not been validated in all languages and cultures, and it may not capture the severity or subtype of delirium.
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Other tools that can be used to assess delirium include the Delirium Observation Screening Scale (DOSS), which is based on 13 behavioral observations; the Nursing Delirium Screening Scale (Nu-DESC), which is based on five symptoms; the Delirium Rating Scale-Revised-98 (DRS-R-98), which is based on 16 items; and the Memorial Delirium Assessment Scale (MDAS), which is based on 10 items. These tools vary in their complexity, validity, reliability, feasibility, and applicability in different settings and populations. Therefore, nurses should choose the tool that best suits their needs and preferences.
How to Intervene for Delirium?
The management of delirium involves identifying and treating the underlying cause(s), preventing complications, providing supportive care, and involving patients and families in decision making. Nurses play a key role in all these aspects of care.
Nurses can help identify and treat the underlying cause(s) of delirium by conducting a thorough assessment of the patient's history, medications, infections, metabolic disturbances, pain, dehydration,
constipation,
urinary retention,
sleep deprivation,
sensory impairment,
and environmental factors.
Nurses can also monitor the patient's vital signs,
laboratory results,
and response to treatment,
and report any changes or concerns to the physician.
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Nurses can help prevent complications of delirium by implementing non-pharmacological interventions,
such as orienting the patient to time,
place,
and person;
providing adequate lighting,
noise reduction,
and temperature control;
ensuring safety measures,
such as bed rails,
call bells,
and fall prevention;
promoting mobility,
hydration,
nutrition,
and elimination;
minimizing invasive procedures,
restraints,
and catheters;
and avoiding anticholinergic,
sedative-hypnotic,
and opioid medications.
Nurses can help provide supportive care for delirium by using person-centered communication,
such as speaking slowly,
clearly,
and calmly;
using simple and concrete words;
repeating and rephrasing information;
using non-verbal cues,
such as eye contact,
touch,
and gestures;
validating the patient's feelings and experiences;
and avoiding confrontation,
argument,
or criticism.
Nurses can also provide psychosocial support,
such as engaging the patient in meaningful activities,
stimulating the patient's senses and cognition,
and providing reassurance and comfort.
Nurses can help involve patients and families in decision making by providing education and information about delirium,
its causes,
symptoms,
course,
and treatment;
encouraging family presence and participation in care;
respecting the patient's preferences and values;
and facilitating advance care planning and palliative care when appropriate.
Conclusion
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Delirium is a common and serious condition that affects many hospitalized patients, especially older adults. It is characterized by acute changes in cognition, attention, awareness, and behavior, and it can have negative consequences for patient outcomes and quality of life. Therefore, it is essential that nurses have the skills to recognize and assess delirium in their patients, and to intervene appropriately. Nurses can use various tools and strategies to screen, diagnose, manage, and prevent delirium, and to provide holistic and compassionate care for patients and their families.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- Bellelli, G., Morandi, A., Davis, D. H., Mazzola, P., Turco, R., Gentile, S., ... & MacLullich, A. M. (2014). Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and ageing, 43(4), 496-502.
- Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922.
- Wong, C. L., Holroyd-Leduc, J., Simel, D. L., & Straus, S. E. (2010). Does this patient have delirium?: value of bedside instruments. Jama, 304(7), 779-786.
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