coGNITIVE DISORDER:delirium

Group 3A

COGNITION IS THE BRAIN’S ability to process, retain, and use information.

Cognitive abilities include: ReasoningJudgmentPerceptionAttentionComprehensionmemory.

These cognitive abilities are essential for many important tasks, including making decisions, solving problems, interpreting the environment, and learning new information.

A cognitive disorder is a disruption or impairment in these higher-level functions of the brain.

They can cause people to forget the names of immediate family members, to be unable to perform daily household tasks, and to neglect personal hygiene (Davis, 2005).

The primary categories of cognitive disorders are delirium, dementia, and amnestic disorders.

All involve impairment of cognition, but they vary with respect to cause, treatment, prognosis, and effect on clients and family members or caregivers.

DELIRIUM

Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition.

Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day.

Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations.

An electrical cord on the floor may appear to them to be a snake (illusion).

They may mistake\ the banging of a laundry cart in the hallway for a gunshot (misinterpretation).

They may see “angels” hovering above when nothing is there (hallucination).

At times, they also experience disturbances in the sleep–wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy

Delirium is common in older acutely ill clients

ETIOLOGY

Delirium almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal

Often, delirium results from multiple causes and requires a careful and thorough physical examination and laboratory tests for identification.

Treatment and PrognosisPsychopharmacologyClients with quiet, hypoactive delirium need

no specific pharmacologic treatment aside from that indicated for the causative condition.

Sedation to prevent inadvertent self-injury may be indicated

An antipsychotic medication, such as haloperidol (Haldol), may be used in doses of 0.5 to 1 mg to decrease agitation.

Sedatives and benzodiazepines are avoided because they may worsen delirium

Clients with impaired liver or kidney function could have difficulty metabolizing or excreting sedatives.

The exception is delirium induced by alcohol withdrawal, which usually is treated with benzodiazepines

Other Medical TreatmentWhile the underlying causes of delirium

are being treated, clients also may need other supportive physical measures.

Adequate nutritious food and fluid intake speed recovery.

Intravenous fluids or even total parenteral nutrition may be necessary

if a client’s physical condition has deteriorated and he or she cannot eat and drink

If a client becomes agitated and threatens to dislodge

intravenous tubing or catheters, physical restraints may be necessary so that needed medical treatments can continue.

Restraints are used only when necessary and stay in place no longer than warranted because they may increase the client’s agitation.

CLINICAL VIGNETTE

On a hot and humid August afternoon, the 911 dispatcher received a call requesting an ambulance for an elderly woman who had collapsed on the sidewalk in a residential area. According to neighbors gathered at the scene, the woman had been wandering around the neighborhood since early morning. No one recognized her and several people had tried to

approach her to offer help or give directions. She would not or could not give her name or address; much of her speech was garbled and hard to understand. She was not carrying a purse or identification. She finally collapsed and appeared unconscious, so they called emergency services. The woman was taken to the emergency room. She was perspiring

profusely, was found to have a fever of 103.2°F, and was grossly dehydrated. Intravenous therapy was started to replenish fluids and electrolytes. A cooling blanket was applied to lower her temperature, and she was monitored closely over the next several hours. As the woman began to regain consciousness, she was confused and could not provide

any useful information about herself. Her speech remained garbled and confused. Several times she attempted to climb out of the bed and remove her intravenous device, so restraints were used to prevent injury and to allow treatment to continue.

By the end of the second day in the hospital, she could accurately give her name, address, and some of the circumstances

surrounding the incident. She remembered she had been gardening in her backyard in the sun and felt very hot. She remembered thinking she should go back in the house to get a cold drink and rest. That was the last thing she remembered.

History

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 medications.

General Appearance and Motor Behavior

have a disturbance of psychomotor behavior. restless and hyperactive Frequently picking at bedclothes or making

sudden uncoordinated attempts to get out of bed 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

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

May call out or scream, especially at night.

Mood and Affect

have rapid and unpredictable mood shiftsanxiety fear Irritability Anger

Thought Process and Content

Clients with delirium have changes in cognition

it is difficult to assess these changes accurately and thoroughly

Marked inability to sustain attention 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.

disorganized and make no sense fragmented (disjointed and incomplete) exhibit delusions

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 environment 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 effectively, and there is impaired recent and immediate memory(APA, 2000).

Clients frequently experience misinterpretations, illusions, and hallucinations.

Judgment and Insight

Judgment is impaired. Clients often cannot perceive potentially

harmful situations or act in their own best interests. For example, they may try repeatedly

to pull out intravenous tubing or urinary catheters; this causes pain and interferes with necessary treatment.

Insight depends on the severity of the delirium.

Clients with mild delirium may recognize that they are confused, 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 functioning, however, and have no longstanding problems with roles or relationships.

Self-Concept

Although delirium has no direct effect on self-concept, clients often are frightened or feel threatened.

Those with some awareness of the situation may feel helpless or powerless 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 humiliation or think, “I’m a bad person; I did this to myself.”

This would indicate possible long-term problems with selfconcept.

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 complete reversal of the usual daytime waking/nighttime sleeping 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 InjuryAcute Confusion

Additional diagnoses that are commonly selected based on client assessment include the following:Disturbed Sensory PerceptionDisturbed Thought ProcessesDisturbed Sleep PatternRisk for Deficient Fluid VolumeRisk 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.

Nursing Interventions for Delirium

 • Promoting client’s safetyTeach client to request assistance for

activities (getting out of bed, going to bathroom).

Provide close supervision to ensure safety during these activities. Promptly respond to client’s call for assistance.

Managing client’s confusionSpeak to client in a calm manner in a clear low

voice; use simple sentences.Allow adequate time for client to comprehend

and respond.Allow client to make decisions as much as able.Provide orienting verbal cues when talking with

client.Use supportive touch if appropriate.

Controlling environment to reduce sensory overload

Keep environmental noise to minimum (television, radio).

Monitor client’s response to visitors; explain to family and friends that client may need to visit quietly one on one.

Validate client’s anxiety and fears, but do not reinforce misperceptions.

Promoting sleep and proper nutritionMonitor sleep and elimination patterns.Monitor food and fluid intake; provide

prompts or assistance to eat and drink adequate amounts of

food and fluids.Provide periodic assistance to bathroom if

client does not make requests.

Discourage daytime napping to help sleep at night.

Encourage some exercise during day like sitting in a chair, walking in hall, or other activities client can

manage.

EvaluationUsually, successful treatment of the

underlying causes of delirium returns clients to their previous levels of functioning. Clients and caregivers or family must understand what health care practices are necessary to avoid a recurrence. This may involve monitoring a chronic health condition,

using medications carefully, or abstaining from alcohol or other drugs.