NUR 414A Delirium

what must you do immediately for delirium

-neuro/physical exam -blood tests -UA -find the medical cause of disorientation `

when is delirium most common

in hospitalized pt, especially older

what are the risk factors of delirium

-acute illness -being in the hospital -bodily stress -pneumonia -myocardial infarction -UTI -toxic response to meds -polypharmacy -allergies -hydration -electrolyte imbalance -bowel and bladder dysfunction

s/s of delirium

-alteration of consciousness -abrupt onset of clinical features that fluctuate -disorganized thinking -poor executive functioning -disorientation -anxiety -agitation -restlessness -poor memory -delusional thinking

what are the goals of treating a pt with delirium

-underlying cause is found and treated -pt stays safe

what is delirium

acute cognitive disturbance and a reversible condition acute and fluctuating onset

delirium is a _______ and you need to intervene so there is not more medical damage

medical emergency

what cognitive and perceptual disturbances are r/t delirium

-deficits in attention, memory, perceptual disturbances (illusion, delusion, hallucination) -usually self-aware that their thoughts are jumbled or wrong

what are effective interventions for the management of delirium

-proper lighting -eye glasses/hearing aids -monitor self-care deficits (skin breakdown, poor nutrition, incontinence) -meds that can cause delirium -assess fluctuating levels of awareness -priority: ensure safety -vitals, LOC, prevent injuries, avoid falls, comfort care

what are the physical needs related to delirium

-providing a doll or stuffed animal to fidget with can prevent the pt removing medical tubes/equipment -collaborate with health care team to remove or treat causative factors -wanders (bed alarms, room close to nurses station, sitter)

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1.Dementia 2.Schizophrenia 3.Seizure disorder 4.Obsessive-compulsive disorder

1

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1.Use of confabulation 2.Improvement in sleeping 3.Absence of sundown syndrome 4.Presence of personal hygienic care

1

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1.Move the client next to the nurses' station. 2.Use an indirect light source and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night, and maintain a well-lit room.

2

Which assessment finding would be a manifestation associated with dementia? 1.Catatonia 2.Confabulation 3.Presence of ritualistic behaviors 4.Increased display of inhibited behaviors

2