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Delirium Guideline at a Glance (Nursing Practice Guideline)

Delirium Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2014EArsenaultknudsen@uwhealth.org
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Guideline Title: Delirium
Effective Date: November, 2014
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
This content is extracted from the adopted source document: Tullman, D.F., Fletcher, K., and
Foreman, M.D. (2012). Delirium. In A. O’Meara (Ed.), Evidence-based geriatric nursing protocols
for best practice (pp. 1-10). New York, NY: Springer Publishing Company, LLC. Please refer to the
source guideline for complete information.
Target Population: Hospitalized older adults
Nursing Practice Guideline Objectives
To reduce the incidence of delirium in hospitalized older adults
Clinical Questions Considered
Not provided by the source document.
Overview
A. Delirium is a common syndrome in hospitalized older adults and is associated with increased
mortality, hospital costs, and long-term cognitive and functional impairment (Siddiqi et al.,
2006).
B. Delirium can sometimes be prevented with the recognition of high-risk patients,
implementation of a standardized delirium-reduction protocol, and proactive geriatric
consultation (Bruera et al., 2009).
C. Recognition of risk factors and routine screening for delirium should be part of comprehensive
nursing care of older adults (Milisen et al., 2005).
Definition
Definition: Delirium is a disturbance of consciousness with impaired attention and disorganized
thinking or perceptual disturbance that develops acutely, has a fluctuating course, and with
evidence that there is an underlying physiologic or medical condition causing the disorder
(APA, 2000).
II. Practice Recommendations
PARAMETERS OF ASSESSMENT
A. Assess for risk factors (Michaud et al., 2007)
1. Baseline or pre-morbid cognitive impairment (see Chapter 8, Assessing Cognitive
Function)
2. Medications review (see Chapter 17, Reducing Adverse Drug Events)
3. Pain (see Chapter 14, Pain Management)
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

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Contact: Last Revised: 11/2014EArsenaultknudsen@uwhealth.org
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4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia,
hypokalemia)
5. Hypoperfusion/hypoxemia (BP, capillary refill, SpO2)
6. Dehydration (physical signs/symptoms, intake/output, Na1, BUN/Cr)
7. Infection (fever, WBCs with differential, cultures)
8. Environment (sensory overload or deprivation, restraints)
9. Impaired mobility
10. Sensory impairment (vision, hearing)
B. Features of delirium (APA, 2000; Inouye et al., 1990)—assess every shift (see “Resources”
for validated instruments)
1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have difficulty shifting attention
from one focus to another; has difficulty keeping track of what is being said
4. Orientation: Disoriented to time and place; should not be disoriented to person
5. Memory: Inability to recall events of hospitalization and current illness; unable to
remember instructions; forgetful of names, events, activities, current news, and so
forth
6. Thinking: Disorganized thinking; rambling, irrelevant, incoherent conversation;
unclear or illogical flow of ideas; or unpredictable switching from topic to topic;
difficulty in expressing needs and concerns; speech may be garbled
7. Perception: Perceptual disturbances such as illusions and visual or auditory
hallucinations; and misperceptions such as calling a stranger by a relative’s name.
NURSING CARE STRATEGIES
(based on protocols in multicomponent delirium prevention studies [Inouye et al., 1999;
Lundstrom et al., 2007; Marcantonio, Flacker, Wright, & Resnick, 2001])
A. Obtain geriatric consultation.
B. Eliminate or minimize risk factors.
1. Administer medications judiciously; avoid high-risk medications (see Chapter17,
Reducing Adverse Drug Events).
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control (see Chapter 14, Pain Management).
5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as
needed).
6. Use sensory aids as appropriate.
7. Regulate bowel/bladder function.
8. Provide adequate nutrition (see Chapter 22, Nutrition).
C. Provide a therapeutic environment.
1. Foster orientation: frequently reassure and reorient patient (unless patient
becomes agitated); use easily visible calendars, clocks, caregiver identification;
carefully explain all activities; communicate clearly.
2. Provide appropriate sensory stimulation: quiet room; adequate light; one task at a
time; noise reduction strategies.
3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation
music/tapes; noise reduction measures; avoid awaking patient.
4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar
objects from home; maintain consistency of caregivers; minimize relocations.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2014EArsenaultknudsen@uwhealth.org
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5. Maximize mobility: avoid restraints (see Chapter 13, Physical Restraints and Side
Rails in Acute and Critical Care Settings) and urinary catheters; ambulate or active
ROM three times daily.
6. Communicate clearly, provide explanations.
7. Reassure and educate family (see Chapter 24, Family Caregiving).
8. Minimize invasive interventions.
9. Consider psychotropic medication as a last resort for agitation.
FOLLOW-UP MONITORING OF CONDITION
A. Decreased delirium to become a measure of quality care
B. Incidence of delirium to decrease
C. Patient days with delirium to decrease
D. Staff competence in recognition and treatment of acute confusion/delirium
E. Documentation of a variety of interventions for acute confusion/delirium
II. Pertinent Resources
A. UWHC Policy
• Policy 3.5.2 Screening, Assessment and Reassessment of Patients
• Policy 2.4.2 Restraint and Seclusion
• Policy 13.23 Application of Physical Restraint
• Policy 14.40 Constant Observation
B. Clinical Tools
• Confusion Assessment Method
o Confusion Assessment Method Scale (CAM) (pdf)
o CAM User Guide
o CAM-ICU User Guide (pdf)
o Confusion Assessment Method-ICU Flowsheet (CAM-ICU Flowsheet) (pdf)
• ACE Delirium Fact Sheet for Nurses (doc)
• Algorithm for Nursing Management of Patients with Delirium (doc)
• Delirium Risk Factor Assessment Reference & Nursing Interventions (pdf)
• Recommendations for Frequency of Assessment for Delirium and Resource List (doc)
• Sedation Scale
• Consult GeriRN - https://consultgeri.org/
An online resources containing information regarding assessing and caring for older
adults sponsored by the Hartford Institute for Geriatric Nursing at New York University
College of Nursing. https://consultgeri.org/
• ICU Delirium and Cognitive Impairment Study Group
• Hospital Elderlife Program
IV. References
See full guideline document for list of references.
V. Summary of Literature Used

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Contact: Last Revised: 11/2014EArsenaultknudsen@uwhealth.org
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Level of Evidence*
Number of
articles
I: Systematic Reviews 6
II: Single experimental study (RCT’s) 13
III: Quasi-experimental studies 0
IV: Non-experimental studies 20
V: Case report/program evaluation/narrative literature reviews 5
VI: Opinions of respected authorities 2
*Levin, R.F. & Kaplan Jacobs, S. (2012). Developing and evaluating clinical practice guidelines: A
systematic approach. In A. O’Meara (Ed.), Evidence-based geriatric nursing protocols for best practice
(pp. 1-10). New York, NY: Springer Publishing Company, LLC.