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Concepts in Gerontological Nursing > Delirium & Case Study > Flashcards

Delirium & Case Study Flashcards

1
Q

CS: Delirium
You are the nurse working on the surgical floor. One of your patients, M.M., a 70-year-old man, was transferred in last night from the ICU. He is postop day 3 after a Whipple procedure for pancreatic cancer. M.M. is NPO and has an NG tube to continuous low wall suction, an indwelling urinary catheter, and a triple-lumen subclavian catheter with D5NS at 75 mL/hr. The abdominal dressing is dry and intact, with Jackson-Pratt drains to bulb suction.

Midway through the morning, M.M.’s daughter comes to the nurses’ station and tells you that there is something wrong” with her father. She said her mother and she just arrived and were speaking with him about his night. He told them he was worried because he saw a nurse wheel his granddaughter down the hall on a stretcher and that from his window, he could see the men on the roof of the building across the street aiming guns at her room and his room.

Using the mnemonic “DELIRIUM,” what are the possible causes of M.M.’s confusion?

A

D: Drugs / dehydration
E: Electrolytes / Emotional distress
L: Low Oxygen / lack of sleep / Liver / Lungs / Brain disorders
I: Infections (UTI, Pneumonia, Sepsis)
R: Drugs
I: Immobility
U: Untreated pain / Unfamiliar moments / Under nutrition
M: Metabolic Disorders

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2
Q

You are the nurse working on the surgical floor. One of your patients, M.M., a 70-year-old man, was transferred in last night from the ICU. He is postop day 3 after a Whipple procedure for pancreatic cancer. M.M. is NPO and has an NG tube to continuous low wall suction, an indwelling urinary catheter, and a triple-lumen subclavian catheter with D5NS at 75 mL/hr. The abdominal dressing is dry and intact, with Jackson-Pratt drains to bulb suction.

Midway through the morning, M.M.’s daughter comes to the nurses’ station and tells you that there is something wrong” with her father. She said her mother and she just arrived and were speaking with him about his night. He told them he was worried

  1. What assessment do you need to perform?
A
  • Comprehensive Assessment
  • PANCAPES
  • Full Physical Assessment
  • Vital Signs
  • Lab results (WBC)
  • Specific Assessments
  • Pain Assessment
  • Medications
  • Assessment tool: BEERS
  • Mental Status
  • Neurological status: CAM, GCS
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3
Q

CS Progress:
You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. How should you respond to M.M.?
A
  • Calm and reassuring voice
  • Reorient to time, place and surrounding environment (Incl people in the room)
  • Tell him that you are not experiencing the hallucination with his right now (recognition that it is a hallucination not reality)
  • Ask how the hallucination is affecting him (validating his experience)
  • Consider interventions that might be calming (music, or massage, sensory box) but remember patient centered-ness
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4
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. You would document M.M.’s report of his seeing the men on the building roof aiming guns at his room as he is displaying:
    a. Mania
    b. Delusions
    c. Hallucinations
    d. Flight of ideas
A

C

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5
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. You administer the Confusion Assessment Method (CAM) to M.M., which evaluates for the presence of delirium. Describe the CAM.
A

9 categories of questions
- 4 features for diagnostic algorithm:
- Feature 1: Acute onset and fluctuating course
- Feature 2: Inattention
- Feature 3: Disorganized Thinking
- Feature 4: Altered level of consciousness
- 1&2 and either 3 or 4 are considered a diagnosis of delirium until proved.

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6
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. Besides the symptoms M.M. has, what are other symptoms of delirium?
A
  • Disorganized thinking
  • Poor executive functioning
  • Disorientation
  • Anxiety
  • Agitation
  • Poor recall
  • Delusional thinking
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7
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. Briefly describe the 3 types of delirium.
A
  1. Hyperactive
    - Restless, agitated, and aggressive
    - They may hallucinate and remove tubes or fall out of bed
  2. Hypoactive
    - Inactive, withdrawn and sleepy
  3. Mixed
    - Fluctuates between hypo and hyperactive symptoms
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8
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. Which medication from M.M.’s current list is most likely to be related to his change in mental status?
    a. Omeprazole 40 mg IV once daily
    b. Enoxaparin 30 mg subcutaneous daily
    c. Ondansetron 4 mg IV every 6 hours as needed
    d. Morphine sulfate 4 mg IV every 3 hours as needed
A

D.
Rational: Drug induced delirium is most likely linked to benzodiazepines, opiates, antidepressants and anticonvulsants.

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9
Q

You accompany his daughter back to M.M.’s room to perform an assessment. As soon as you enter the room and reintroduce yourself, he yells, “Get down! The men are back on the roof and are aiming this way!”

  1. M.M.’s wife states that she has never seen her husband act like this before and she is scared. How would you explain what is happening to his family?
A
  • Explain that he is experiencing delirium, explain what delirium is
  • Explain the symptoms: unable to think clearly, inattention, not fully aware of environment
  • Explain duration (a few hours to days)
  • Usually only temporary and reversible if treated - treatment focuses on cause of delirium and avoiding worsening delirium.
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10
Q

CS Progress:
Your assessment findings are as follows: Vital signs 94/72, 109, 32, 100.8° F (38.2° C), Spo2 89% on room air. You auscultate decreased breath sounds and coarse crackles in the left lower lobe posteriorly. M.M. is alert and oriented to name. He does not answer all your questions and is unable to follow simple instructions. There is minimal eye contact and he continues to look furtively out the window. The rest of his assessment is unremarkable.

  1. Score M.M. on the CAM.
A

Meets 1, 2 and 3
- Assume episode of delirium unless otherwise proven

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11
Q

Your assessment findings are as follows: Vital signs 94/72, 109, 32, 100.8° F (38.2° C), Spo2 89% on room air. You auscultate decreased breath sounds and coarse crackles in the left lower lobe posteriorly. M.M. is alert and oriented to name. He does not answer all your questions and is unable to follow simple instructions. There is minimal eye contact and he continues to look furtively out the window. The rest of his assessment is unremarkable.

  1. You believe his delirium may be associated with hypoxia and fever from atelectasis. Using SBAR, outline the report you need to give to the provider.
A

S: Identify yourself and patient and explain patient’s sudden onset of confusion, changes in VS and lung sounds.
B: Post operative day 3 after Whipple procedure for pancreatic cancer.
A: Focus on SpO2 sats 89%, VS findings; auscultated decreased breath sounds and coarse crackles in LLL posteriorly; results of neurological assessment and CAM results
R: Patient is experiencing….

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12
Q

CS Progress:
Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:
Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. What outcome is associated with each of the medications ordered for M.M.?
A

Ceftriaxone:
- Cephalosporin AB (broad spectrum)

Albuterol:
- Combination nebuliser: Fast acting beta 2 agonist: anticholinergic: both cause bronchodilation and clear secretions.

Acetaminophen:
- Reduce fever and general discomfort

Haloperidol:
- Antipsychotic medication for short term management of acute agitation

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13
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:
Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. What are the health care team’s primary goals for M.M. at this time?
A

Promote respiratory function: treat infection and prevent injury

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14
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:
Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. Write an outcome statement addressing M.M.’s risk for injury.
A

For example:
- Return to previous functioning but consider impact of pancreatic cancer
- Remining safe and injury free during delirious phase
- Safe and supportive discharge

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15
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:
Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. What is the focus of the ongoing assessment you need to perform?
A
  • VS
  • Respiratory and neurological status
  • Repeated CAM
  • Lab results especially WBC
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16
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:
Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. Describe the physical changes you should make to M.M.’s environment to promote safety.
A
  • Bed alarms
  • Call bell in reach
  • Provide familiar objects
  • Put something in the rom to orientate to time and place (clock, and white board)
  • Reorient to yourself / providers (introduce yourself each time)
  • Good lighting
  • Clean space no hazards
  • Bed in low position
  • Bed rails
17
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:

Medication Orders:
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

18. Another nurse tells you that you must apply restraints to protect M.M. from injury. How do you respond?
A
  • Restraints might cause more distress and an increased risk for injury.
  • Ensure everything is within reach.
  • Having a one-to-one; someone to sit with them.
18
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:

Medication Orders
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. What other interventions can you use to promote orientation? Select all that apply.
    a. Place the television on a news channel
    b. Refrain from administering pain medications
    c. Have him wear his hearing aid and eye glasses
    d. Orient M.M. of person, place, and time, as needed
    e. Encourage his family to “go along” with his hallucinations
    f. Reintroduce him to health care providers with each contact
A

C, D, F

19
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:

Medication Orders
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. How should you communicate with M.M.?
A
  • Keep it simple and clear
  • Short sentences
  • Early instructions to follow
  • Avoid irritating patient more
  • Stay calm
  • Approach from the front
  • Don’t quiz patient - especially with questions that are complexity.
  • Assess frustration and adjust communication style and information giving accordingly.
20
Q

Hearing your report, the provider orders oxygen therapy, blood cultures, CBC with differential, basic metabolic panel, ECG, and a chest x-ray now and in the morning. The chest x-ray confirms the presence of atelectasis in the left lower lobe. His blood chemistry findings and CBC are all within normal limits except for WBC count, which is elevated at 11600/ mm3 (11.6 x 109/L). The provider orders the following:

Medication Orders
- Ceftriaxone 1 gram IV q12h
- Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
- Acetaminophen 650 mg PO q6h
- Haloperidol 0.5 mg IV q3h as needed for agitation

  1. Which tasks are appropriate to assign to the PSW assisting you with M.M.’s care? Select all that apply.
    a. Keeping the call light within M.M.’s reach
    b. Ambulating M.M. to the chair and bathroom
    c. Assisting M.M. with performing oral hygiene
    d. Emptying the two Jackson-Pratt drains each shift
    e. Obtaining routine vital signs and M.M.’s daily weight
A

A, B, C, E

21
Q

Pancreatic Cancer

A
  • Risk of developing pancreatic cancer increases with age, 2/3 are >65 years
  • Slightly more men than women are affected by pancreatic cancer
  • Cigarette smoking is one of the biggest risk factors for pancreatic cancer
  • Pancreatic cancer is seldom detected in the early , most curable stages, because it doesn’t cause symptoms until it has spread to other organs
  • Combined 5 year survival rate for pancreatic cancer - is very low at just 5-10%.
22
Q

Whipple Procedure

A
  • Primary surgical treatment for pancreatic cancer that occurs within the head of the gland
  • Removal of the head of the pancreas, most of the duodenum (a part of the small intestine), a portion of the bile duct, the gallbladder and associated lymph nodes
  • Most patient’s stay in the hospital for one to two weeks following the Whipple procedure.
23
Q

What are the main reasons/underlying causes for confusion in older people?

A
  • Infection
  • Hypoglycemia
  • Side effects of drugs
  • Untreated pain
  • Dehydration
  • Hypoxia
  • Anxiety, depression, psychosis
  • Delirium
  • Underlying pathophysiology: dementia
  • *Confusion is NOT a normal sign of ageing
24
Q

Delirium: a Case of misdiagnosis, lack of recognition and discrimination?

A
  • Frequently unrecognized or misdiagnosed in up to 70% of older patient’s
  • Often misdiagnosed as mood disorders or dementia
  • Particular groups of people face additional delayed diagnosis and misdiagnosis as a result of discrimination and systemic racism
  • The term “excited delirium” often used as a reason by police to restrain racialized groups and reported as cause of death in police custody.
  • Untreated delirium can have a devastating consequences in older patient’s with high morbidity and mortality.
25
Q

Delegation

A
  • Delegation is a process by which a healthcare professional who has legal authority to perform a controlled act transfers that authority to an unauthorized person
  • There are 14 controlled acts in the regulated health professions act, 1991. By definition, a controlled act can cause harm if it is performed by an individual who is not competent.
  • The regulation set out the categories and classes of nurses who can delegate (for ex. RNs and RPNs in the general class, and NPs)
  • It also prohibits delegating certain controlled acts (ex. NPs cannot delegate setting a fracture)
  • The regulation lists the requirements to delegate and to accept delegation (ex. Considering the best interests of the client) as well as the requirements for documenting the delegation
  • Sub-delegation is prohibited. Sub-delegation occurs when an individual who accepts a delegation then delegates the same act to another person. This is not allowed because the individual who is sub-delegation does not have legal authority to perform the act without delegation.

Concepts in Gerontological Nursing (6 decks)

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