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Chapter: Psychiatric Mental Health Nursing : Child and Adolescent Disorders

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Application of the Nursing Process: Delirium

Nursing care for clients with delirium focuses on meeting their physiologic and psychologic needs and maintaining their safety.

APPLICATION OF THE NURSING PROCESS: DELIRIUM

 

Nursing care for clients with delirium focuses on meeting their physiologic and psychologic needs and maintaining their safety. Behavior, mood, and level of consciousness of these clients can fluctuate rapidly throughout the day. Therefore, the nurse must assess them continuously to recognize changes and to plan nursing care accordingly.

 

Assessment

 

History

 

Because the causes of delirium are often related to medical illness, alcohol, or other drugs, the nurse obtains a thor-ough history of these areas. The nurse may need to obtain information from family members if a client’s ability to provide accurate data is impaired.

 

Information about drugs should include prescribed medications, alcohol, illicit drugs, and over-the-counter med-ications. Although many people perceive prescribed and over-the-counter medications as relatively safe, combinations or standard doses of medications can produce delirium, espe-cially in older adults.



General Appearance and Motor Behavior

 

Clients with delirium often have a disturbance of psychomo-tor behavior. They may be restless and hyperactive, frequently picking at bedclothes or making sudden, uncoordinated attempts to get out of bed. Conversely, clients may have slowed motor behavior, appearing sluggish and lethargic with little movement.

 

Speech also may be affected, becoming less coherent and more difficult to understand as delirium worsens. Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal. At times, cli-ents may call out or scream, especially at night.

 

Mood and Affect

 

Clients with delirium often have rapid and unpredictable mood shifts. A wide range of emotional responses is possi-ble, such as anxiety, fear, irritability, anger, euphoria, and apathy. These mood shifts and emotions usually have noth-ing to do with the client’s environment. When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm.

 

Thought Process and Content

 

Although clients with delirium have changes in cognition, it is difficult for the nurse to assess these changes accurately and thoroughly. Marked inability to sustain attention makes it difficult to assess thought process and content. Thought content in delirium often is unrelated to the situation, or speech is illogical and difficult to understand. The nurse may ask how clients are feeling, and they will mumble about the weather. Thought processes often are disorganized and make no sense. Thoughts also may be fragmented (disjointed and incom-plete). Clients may exhibit delusions, believing that their altered sensory perceptions are real.

Sensorium and Intellectual Processes

 

The primary and often initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. Clients usually are oriented to person but frequently disoriented to time and place. They demonstrate decreased awareness of the environ-ment or situation and instead may focus on irrelevant stimuli such as the color of the bedspread or the room. Noises, people, or sensory misperceptions easily distract them.

 

Clients cannot focus, sustain, or shift attention effec-tively, and there is impaired recent and immediate memory (APA, 2000). This means the nurse may have to ask ques-tions or provide directions repeatedly. Even then, clients may be unable to do what is requested.

 

Clients frequently experience misinterpretations, illu-sions, and hallucinations. Both misperceptions and illu-sions are based on some actual stimuli in the environment: clients may hear a door slam and interpret it as a gunshot or see the nurse reach for an intravenous bag and believe the nurse is about to strike them. Examples of common illusions include clients believing that intravenous tubing or an electrical cord is a snake and mistaking the nurse for a family member. Hallucinations are most often visual: cli-ents “see” things for which there is no stimulus in reality. Some clients, when more lucid, are aware that they are experiencing sensory misperceptions. Others, however, actually believe their misinterpretations are correct and cannot be convinced otherwise.

 

Judgment and Insight

 

Judgment is impaired. Clients often cannot perceive poten-tially harmful situations or act in their own best interests. For example, they may try repeatedly to pull out intrave-nous tubing or urinary catheters; this causes pain and interferes with necessary treatment.

 

Insight depends on the severity of the delirium. Cli-ents with mild delirium may recognize that they are con-fused, are receiving treatment, and will likely improve. Those with severe delirium may have no insight into the situation.

  

Roles and Relationships

 

Clients are unlikely to fulfill their roles during the course of delirium. Most regain their previous level of function-ing, however, and have no longstanding problems with roles or relationships.

 

Self-Concept

 

Although delirium has no direct effect on self-concept, cli-ents often are frightened or feel threatened. Those with some awareness of the situation may feel helpless or pow-erless to do anything to change it. If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humilia-tion or think, “I’m a bad person; I did this to myself.” This would indicate possible long-term problems with self-concept.

 

Physiologic and Self-Care Considerations

 

Clients with delirium most often experience disturbed sleep–wake cycles that may include difficulty falling asleep, daytime sleepiness, nighttime agitation, or even a com-plete reversal of the usual daytime waking/nighttime sleep-ing pattern (APA, 2000). At times, clients also ignore or fail to perceive internal body cues such as hunger, thirst, or the urge to urinate or defecate.

 

Data Analysis

 

The primary nursing diagnoses for clients with delirium are as follows:

 

·    Risk for Injury

 

·    Acute Confusion

 

Additional diagnoses that are commonly selected based on client assessment include the following:

 

·    Disturbed Sensory Perception

 

·    Disturbed Thought Processes

 

·    Disturbed Sleep Pattern

 

·    Risk for Deficient Fluid Volume

 

Risk for Imbalanced Nutrition: Less Than Body Requirements

Outcome Identification

 

Treatment outcomes for the client with delirium may include the following:

 

·    The client will be free of injury.

 

·    The client will demonstrate increased orientation and reality contact.

 

·    The client will maintain an adequate balance of activity and rest.

 

·    The client will maintain adequate nutrition and fluid balance.

 

·    The client will return to his or her optimal level of functioning.

 

Intervention

 

Promoting the Client’s Safety

 

Maintaining the client’s safety is the priority focus of nurs-ing interventions. Medications should be used judiciously because sedatives may worsen confusion and increase the risk for falls or other injuries (Samuels & Neugroschl, 2005).

 

The nurse teaches clients to request assistance for activ-ities such as getting out of bed or going to the bathroom. If clients cannot request assistance, they require close super-vision to prevent them from attempting activities they can-not perform safely alone. The nurse responds promptly to calls from clients for assistance and checks clients at fre-quent intervals.

 

If a client is agitated or pulling at intravenous lines or catheters, physical restraints may be necessary. Use of restraints, however, may increase the client’s fears or feelings of being threatened, so restraints are a last resort. The nurse first tries other strategies such as having a fam-ily member stay with the client to reassure him or her.

 

Managing the Client’s Confusion

 

The nurse approaches these clients calmly and speaks in a clear low voice. It is important to give realistic reassurance to clients, such as

 

“I know things are upsetting and confusing right now, but your confusion should clear as you get better.” (validating/giving information)

Facing clients while speaking helps to capture their attention. The nurse provides explanations that clients can comprehend, avoiding lengthy or too detailed discussions. The nurse phrases questions or provides directions to cli-ents in short, simple sentences, allowing adequate time for clients to grasp the content or to respond to a question. He or she permits clients to make decisions as they are able and takes care not to overwhelm or frustrate them.

 

The nurse provides orienting cues when talking with cli-ents, such as calling them by name and referring to the time of day or expected activity. For example, the nurse might say,

 

“Good morning, Mrs. Jones. I see you are awake and look ready for breakfast.” (giving information) 

 

Reminding the client of the nurse’s name and role repeat-edly may be necessary, such as

 

“My name is Sheila, and I’m your nurse today. I’m here now to walk in the hall with you.” (re-ality orientation)

 

Orienting objects such as a calendar and clock in the client’s room are useful.

 

Often, the use of touch reassures clients and provides contact with reality. It is important to evaluate each client’s response to touch rather than to assume all clients wel-come it. A client who smiles or draws closer to the nurse when touched is responding positively. The fearful client may perceive touch as threatening rather than comforting and startle or draw away.

 

Clients with delirium can experience sensory overload, which means more stimulation is coming into the brain than they can handle. Reducing environmental stimulation is helpful because these clients are distracted and overstim-ulated easily. Minimizing environmental noises, including television or radio, should calm them. It is also important to monitor response to visitors. Too many visitors or more than one person talking at once may increase the client’s confusion. The nurse can explain to visitors that the client will best tolerate quiet talking with one person at a time.

 

The client’s room should be well lit to minimize environ-mental misperceptions. When clients experience illusions or misperceptions, the nurse corrects them matter-of-factly. It is important to validate the client’s feelings of anxiety or fear generated by the misperception but not to reinforce that misperception. For example, a client hears a loud noise in the hall and asks the nurse, “Was that an explosion?” The nurse might respond,

“No, that was a cart banging in the hall. It was really loud, wasn’t it? It startled me a little when I heard it.” (presenting reality/validat-ing feelings)

Promoting Sleep and Proper Nutrition

 

The nurse monitors the client’s sleep and elimination pat-terns and food and fluid intake. Clients may require prompt-ing or assistance to eat and drink adequate food and fluids. It may be helpful to sit with clients at meals or to frequently offer fluids. Family members also may be able to help cli-ents to improve their intake. Assisting clients to the bath-room periodically may be necessary to promote elimination if clients do not make these requests independently.

 

Promoting a balance of rest and sleep is important if clients are experiencing a disturbed sleep pattern. Dis-couraging or limiting daytime napping may improve abil-ity to sleep at night. It is also important for clients to have some exercise during the day to promote nighttime sleep. Activities could include sitting in a chair, walking in the hall, or engaging in diversional activities (as possible).

 

Evaluation

 

Usually, successful treatment of the underlying causes of delirium returns clients to their previous levels of func-tioning. Clients and caregivers or family must understand what health care practices are necessary to avoid a recur-rence. This may involve monitoring a chronic health con-dition, using medications carefully, or abstaining from alcohol or other drugs.

 

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