coGNITIVE DISORDER: delirium

Group 3A

 COGNITION IS THE BRAINS ability to process, retain, and use infor ation! Co"niti#e abilities include$ Reasonin" %ud" ent &erception Attention Co pre'ension e ory!

 T'ese co"niti#e abilities are essential for any i portant tas(s, includin" a(in" decisions, sol#in" proble s, interpretin" t'e en#iron ent, and learnin" ne) infor ation! A co"niti#e disorder is a disruption or i pair ent in t'ese 'i"'er*le#el functions of t'e brain!

 T'ey can cause people to for"et t'e na es of i ediate fa ily e bers, to be unable to perfor daily 'ouse'old tas(s, and to ne"lect personal 'y"iene +,a#is, -../0! T'e pri ary cate"ories of co"niti#e disorders are deliriu , de entia, and a nestic disorders!

 All in#ol#e i pair ent of co"nition, but t'ey #ary )it' respect to cause, treat ent, pro"nosis, and effect on clients and fa ily e bers or care"i#ers!

DELIRIUM
Delirium is a syndro e t'at in#ol#es a disturbance of consciousness acco panied by a c'an"e in co"nition! ,eliriu usually de#elops o#er a s'ort period, so eti es a atter of 'ours, and fluctuates, or c'an"es, t'rou"'out t'e course of t'e day!

 Clients )it' deliriu 'a#e difficulty payin" attention, are easily distracted and disoriented, and ay 'a#e sensory disturbances suc' as illusions, isinterpretations, or 'allucinations! An electrical cord on t'e floor ay appear to t'e to be a sna(e +illusion0! T'ey ay ista(e1 t'e ban"in" of a laundry cart in t'e 'all)ay for a "uns'ot + isinterpretation0!

 T'ey ay see 2an"els3 'o#erin" abo#e )'en not'in" is t'ere +'allucination0! At ti es, t'ey also e4perience disturbances in t'e sleep5)a(e cycle, c'an"es in psyc'o otor acti#ity, and e otional proble s suc' as an4iety, fear, irritability, eup'oria, or apat'y ,eliriu is co on in older acutely ill clients

ETIOLOGY
,eliriu al ost al)ays results fro an identifiable p'ysiolo"ic, etabolic, or cerebral disturbance or disease or fro dru" into4ication or )it'dra)al Often, deliriu results fro ultiple causes and re6uires a careful and t'orou"' p'ysical e4a ination and laboratory tests for identification!

Treatment and Prognosis

Psyc op armacology Clients )it' 6uiet, 'ypoacti#e deliriu need no specific p'ar acolo"ic treat ent aside fro t'at indicated for t'e causati#e condition! Sedation to pre#ent inad#ertent self*in7ury ay be indicated An antipsyc'otic edication, suc' as 'aloperidol +Haldol0, ay be used in doses of .!/ to 8 " to decrease a"itation!

 Sedati#es and ben9odia9epines are a#oided because t'ey ay )orsen deliriu Clients )it' i paired li#er or (idney function could 'a#e difficulty etaboli9in" or e4cretin" sedati#es! T'e e4ception is deliriu induced by alco'ol )it'dra)al, )'ic' usually is treated )it' ben9odia9epines

 Ot er Medical Treatment :'ile t'e underlyin" causes of deliriu are bein" treated, clients also ay need ot'er supporti#e p'ysical easures! Ade6uate nutritious food and fluid inta(e speed reco#ery! Intra#enous fluids or e#en total parenteral nutrition ay be necessary

 if a clients p'ysical condition 'as deteriorated and 'e or s'e cannot eat and drin( If a client beco es a"itated and t'reatens to dislod"e intra#enous tubin" or cat'eters, p'ysical restraints ay be necessary so t'at needed edical treat ents can continue!

 Restraints are used only )'en necessary and stay in place no lon"er t'an )arranted because t'ey ay increase t'e clients a"itation!

!LI"I!AL #IG"ETTE
On a 'ot and 'u id Au"ust afternoon, t'e ;88 dispatc'er recei#ed a call re6uestin" an a bulance for an elderly )o an )'o 'ad collapsed on t'e side)al( in a residential area! Accordin" to nei"'bors "at'ered at t'e scene, t'e )o an 'ad been )anderin" around t'e nei"'bor'ood since early ornin"! No one reco"ni9ed 'er and se#eral people 'ad tried to

approac' 'er to offer 'elp or "i#e directions! S'e )ould not or could not "i#e 'er na e or address< uc' of 'er speec' )as "arbled and 'ard to understand! S'e )as not carryin" a purse or identification! S'e finally collapsed and appeared unconscious, so t'ey called e er"ency ser#ices! T'e )o an )as ta(en to t'e e er"ency roo ! S'e )as perspirin"

profusely, )as found to 'a#e a fe#er of 8.=!->?, and )as "rossly de'ydrated! Intra#enous t'erapy )as started to replenis' fluids and electrolytes! A coolin" blan(et )as applied to lo)er 'er te perature, and s'e )as onitored closely o#er t'e ne4t se#eral 'ours! As t'e )o an be"an to re"ain consciousness, s'e )as confused and could not pro#ide

any useful infor ation about 'erself! Her speec' re ained "arbled and confused! Se#eral ti es s'e atte pted to cli b out of t'e bed and re o#e 'er intra#enous de#ice, so restraints )ere used to pre#ent in7ury and to allo) treat ent to continue! By t'e end of t'e second day in t'e 'ospital, s'e could accurately "i#e 'er na e, address, and so e of t'e circu stances

surroundin" t'e incident! S'e re e bered s'e 'ad been "ardenin" in 'er bac(yard in t'e sun and felt #ery 'ot! S'e re e bered t'in(in" s'e s'ould "o bac( in t'e 'ouse to "et a cold drin( and rest! T'at )as t'e last t'in" s'e re e bered!

$istory
Obtain infor ation fro fa ily e bers if a clients ability to pro#ide accurate data is i paired! Infor ation about dru"s s'ould include prescribed edications, alco'ol, illicit dru"s, and o#er*t'e*counter edications!

General Appearance and Motor %e a&ior

'a#e a disturbance of psyc'o otor be'a#ior! restless and 'yperacti#e ?re6uently pic(in" at bedclot'es or a(in" sudden uncoordinated atte pts to "et out of bed clients ay 'a#e slo)ed otor be'a#ior appearin" slu""is' and let'ar"ic )it' little o#e ent

 Speec' also ay be affected, beco in" less co'erent and ore difficult to understand as deliriu )orsens perse#erate on a sin"le topic or detail, ay be ra blin" and difficult to follo), or ay 'a#e pressured speec' t'at is rapid, forced, and usually louder t'an nor al @ay call out or screa , especially at ni"'t!

Mood and A''ect

'a#e rapid and unpredictable an4iety fear Irritability An"er ood s'ifts

T oug t Process and !ontent

Clients )it' deliriu 'a#e c'an"es in co"nition it is difficult to assess t'ese c'an"es accurately and t'orou"'ly @ar(ed inability to sustain attention unrelated to t'e situation, or speec' is illo"ical and difficult to understand

 T'e nurse ay as( 'o) clients are feelin", and t'ey )ill u ble about t'e )eat'er! disor"ani9ed and a(e no sense fra" ented +dis7ointed and inco plete0 e4'ibit delusions

(ensorium and Intellectual Processes

T'e pri ary and often initial si"n of deliriu is an altered le#el of consciousness t'at is seldo stable and usually fluctuates t'rou"'out t'e day! Clients usually are oriented to person but fre6uently disoriented to ti e and place! T'ey de onstrate decreased a)areness of t'e en#iron ent or situation and instead ay focus on irrele#ant sti uli suc' as t'e color of t'e bedspread or t'e

 Noises, people, or sensory isperceptions easily distract t'e ! Clients cannot focus, sustain, or s'ift attention effecti#ely, and t'ere is i paired recent and i ediate e ory+A&A, -...0! Clients fre6uently e4perience isinterpretations, illusions, and 'allucinations!

)udgment and Insig t

%ud" ent is i paired! Clients often cannot percei#e potentially 'ar ful situations or act in t'eir o)n best interests! ?or e4a ple, t'ey ay try repeatedly to pull out intra#enous tubin" or urinary cat'eters< t'is causes pain and interferes )it' necessary treat ent!

 Insi"'t depends on t'e se#erity of t'e deliriu ! Clients )it' ild deliriu ay reco"ni9e t'at t'ey are confused, are recei#in" treat ent, and )ill li(ely i pro#e! T'ose )it' se#ere deliriu ay 'a#e no insi"'t into t'e situation!

Roles and Relations ips

Clients are unli(ely to fulfill t'eir roles durin" t'e course of deliriu ! @ost re"ain t'eir pre#ious le#el of functionin", 'o)e#er, and 'a#e no lon"standin" proble s )it' roles or relations'ips!

(el'*!oncept
Alt'ou"' deliriu 'as no direct effect on self*concept, clients often are fri"'tened or feel t'reatened! T'ose )it' so e a)areness of t'e situation ay feel 'elpless or po)erless to do anyt'in" to c'an"e it!

 If deliriu 'as resulted fro alco'ol, illicit dru" use, or o#eruse of prescribed edications, clients ay feel "uilt, s'a e, and 'u iliation or t'in(, 2I a bad person< I did t'is to yself!3 T'is )ould indicate possible lon"*ter proble s )it' selfconcept!

P ysiologic and (el'*!are !onsiderations

Clients )it' deliriu ost often e4perience disturbed sleep5)a(e cycles t'at ay include difficulty fallin" asleep, dayti e sleepiness, ni"'tti e a"itation, or e#en a co plete re#ersal of t'e usual dayti e )a(in"Ani"'tti e sleepin" pattern +A&A, -...0! At ti es, clients also i"nore or fail to percei#e internal body cues suc' as 'un"er, t'irst, or t'e ur"e to urinate or defecate

Data Analysis

T e primary nursing diagnoses 'or clients +it delirium are as 'ollo+s, Ris( for In7ury Acute Confusion

 Additional diagnoses t at are commonly selected -ased on client assessment include t e 'ollo+ing, ,isturbed Sensory &erception ,isturbed T'ou"'t &rocesses ,isturbed Sleep &attern Ris( for ,eficient ?luid Bolu e Ris( for I balanced Nutrition$ Cess T'an Body Re6uire ents

Outcome Identi'ication
Treat ent outco es for t'e client )it' deliriu ay include t'e follo)in"$ T'e client )ill be free of in7ury! T'e client )ill de onstrate increased orientation and reality contact! T'e client )ill aintain an ade6uate balance of acti#ity and rest! T'e client )ill aintain ade6uate nutrition and fluid balance! T'e client )ill return to 'is or 'er opti al le#el of functionin"!

"ursing Inter&entions 'or Delirium

. Promoting client/s sa'ety Teac' client to re6uest assistance for acti#ities +"ettin" out of bed, "oin" to bat'roo 0! &ro#ide close super#ision to ensure safety durin" t'ese acti#ities! &ro ptly respond to clients call for assistance!

 Managing client/s con'usion Spea( to client in a cal anner in a clear lo) #oice< use si ple sentences! Allo) ade6uate ti e for client to co pre'end and respond! Allo) client to a(e decisions as uc' as able! &ro#ide orientin" #erbal cues )'en tal(in" )it' client! Dse supporti#e touc' if appropriate!

 !ontrolling en&ironment to reduce sensory o&erload Eeep en#iron ental noise to ini u +tele#ision, radio0! @onitor clients response to #isitors< e4plain to fa ily and friends t'at client ay need to #isit 6uietly one on one! Balidate clients an4iety and fears, but do not reinforce isperceptions!

 Promoting sleep and proper nutrition @onitor sleep and eli ination patterns! @onitor food and fluid inta(e< pro#ide pro pts or assistance to eat and drin( ade6uate a ounts of food and fluids! &ro#ide periodic assistance to bat'roo if client does not a(e re6uests!

,iscoura"e dayti e nappin" to 'elp sleep at ni"'t! Encoura"e so e e4ercise durin" day li(e sittin" in a c'air, )al(in" in 'all, or ot'er acti#ities client can ana"e!

E&aluation
Dsually, successful treat ent of t'e underlyin" causes of deliriu returns clients to t'eir pre#ious le#els of functionin"! Clients and care"i#ers or fa ily ust understand )'at 'ealt' care practices are necessary to a#oid a recurrence! T'is ay in#ol#e onitorin" a c'ronic 'ealt' condition, usin" edications carefully, or abstainin" fro alco'ol or ot'er dru"s!