HAL II 4.3 (ICU delirium)

delirium

neuropsychiatric syndrome characterized by acute changes in cognition, attentional deficits & alerted arousal with a fluctuating course

dementia

chronic neurodegenerative syndrome characterized by progressive cognitive changes including memory, executive deficits, & functional decline

true

true or false:

dementia is a significant risk factor for hospital acquired delirium

- older age is also a risk factor

psychosis

abnormalities in delusions, hallucinations, disorganized thought, disorganized or abnormal motor behavior & negative symptoms

ICU delirium

acute onset of cerebral dysfunction characterized by:

1. a change or fluctuation in baseline mental status

2. inattention

3. either disorganized thinking or altered LOC

delirium risk factor

- Drugs

- Eyes, ear, or other sensory deficits

- Low O2 stats

- Infection

- Retention (urine, stool)

- Ictal state

- Underhydration/undernutrition

- Metabolic causes (electrolytes)

- Subdural hematoma

THINK delirium

- Toxic situations = CHF, shock, dehydration, new organ failure, sedatives

- Hypoxia

- Infection (sepsis)/immbolity

- Nonpharm = glasses, hearing aids, sleep protocol, noise control, ambulation, music

- K or electrolyte problems

ICU delirium patho

1. neurotransmitter dysregulation: dopamine & AcH

2. aging brain: >65

3. neuro inflammation: meningitis, alcohol, lupus, DM

4. hypoxia: decrease O2

5. mitochondrial dysfunction

6. systemic inflammation

types of delirium

1. hyperactive

2. hypoactive

3. mixed

hyperactive delirium

delirium characterized by agitation, restlessness, hallucinations, & emotional instability

- should be immediately investigated

hypoactive delirium

delirium characterized by confusion, lethargy, sedation, slowed motor function

- often underrated & has the worst outcome

delirium nursing management

A - assess & manage pain

B - both awakening & breathing trials

C - choice of sedation & analgesia meds

D - delirium assessment

E - early progressive mobility

F - family engagement & empowerment

pain management

- assess for pain routinely

- pre-medicate for procedures, therapy & repositioning

- treat pain prior to considering sedation

use the non verbal pain scale (NVP)

- A in ABCDEF bundle

pain med alternatives

a. acetaminophen IV, PO, PR

b. ketamine low dose

c. neuropathic - gabapentin, carbamazepine

d. massage

e. music (calm)

f. cold packs

awakening, breathing

perform the ___________ trial first, before performing the _____________ trial for intubated patients

- B in ABCDEF bundle

awakening & breathing trial

1. coordinate with RT, provider

2. wean sedation (turn off)

3. assess neuro status

4. assess ability to breath on own

- if they pass both = extubate

sedation & analgesia meds

use the lightest level of sedation needed; goal RASS -2 or higher

- C in ABCDEF bundle

avoid

_________ opioids & benzos for sedation in the ICU

dexmedetomidine, propofol

what 2 meds are a good choice of sedation & analgesia for ICU?

delirium assessment

1. CAM ICU

2. ICDSC

3. RASS - sedation level

should be done at least once per shift

early progressive mobility

depends on their baseline, but get those limbs moving!

- E in ABCDEF bundle

family engagement

- speak calmly & use simple words/phrases

- reorient pt of day and date

- talk about friends & family

- bring glasses, hearing aids

- decorate room

- favorite music or TV show

- sit with them & help calm them

(F in ABCDEF bundle)

non pharm interventions

- promote sleep & wake cycles

- reorient

- minimize or disguise lines/tubes ex: pillow case over IV

- avoid restraints, use only if become necessary

ICU delirium meds

- dexmedetomidine or propofol instead of benzos for sedation

- haloperidol = EPS risk

- risperidone

- olanzapine

- quetiapine

on tele for a lot of these meds

false

true or false:

antipsychotics can prevent delirium; they are not a treatment option working on the behaviors

RASS

this scale is used to determine the effectiveness of a patient's sedation

CAM ICU

a positive ______________ score would need the intervention of ensuring all elements of the ABCDEF bundle are being followed

- what ICU delirium scale?

dementia characteristics

- alert, disoriented

- steady slow decline

- normal attention & psychomotor

- usually no hallucinations

- usually normal sleep wake cycle

- aphasic, anomic difficulty finding words

- chronic

delirium characteristics

- decrease or hyper alert

- disorganized orientation

- fluctuating course

- impaire attention

- agitated or lethargic psychomotor

- hallucinations

- abnormal sleep wake cycle

- slow, incoherent speech

- acute onset