My grandfather has turned 89 years old 2 months ago. He seems to have changed from then on. He always complains of seeing ants in the ceiling, or ants on the floor beside his bed. He sometimes forgets my name. Lately, he keeps on mumbling to himself and looks agitated. He doesn’t know where he is anymore, or what the present date is. I’m really worried that he is in the early stages of delirium. I think we should have him checked. Show
DescriptionDelirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period (DSM-IV-TR). Statistics and IncidencesDelirium is common in the United States.
CausesThe DSM-IV-TR differentiates among the disorders of delirium by their etiology, although they share a common symptom presentation. Categories of delirium include the following: Differentiating delirium from dementia.
Clinical ManifestationsThe following symptoms have been identified with the syndrome of delirium: Infographic for recognizing the signs and symptoms of delirium. Image via: publichealth.hscni.net
Assessment and Diagnostic FindingsLaboratory tests that may be helpful for diagnosis include the following:
Medical ManagementWhen delirium is diagnosed or suspected, the underlying causes should be sought and treated.
Pharmacologic ManagementDelirium that causes injury to the patient or others should be treated with medications.
Nursing management for a patient with delirium include the following: Nursing AssessmentNursing assessment should include:
Nursing DiagnosisNANDA nursing diagnoses for persons with delirium include:
Nursing Care Planning and GoalsThe major nursing care plan goals for delirium are:
Nursing InterventionsNursing interventions for patients with delirium include the following:
EvaluationThe outcome criteria includes:
Documentation GuidelinesDocumentation in a patient with delirium include:
Practice Quiz: DeliriumNursing practice questions for delirium. Please visit our nursing test bank page for more NCLEX practice questions. 1. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. It’s characterized by an acute onset and lasts about 1 month. 1. Answer: D. It’s characterized by an acute onset and lasts hours to a number of days
2. Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for: A. Occasional irritable outbursts. 2. Answer: B. Impaired communication.
3. Loretta, a newly admitted client was diagnosed with delirium and has a history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions? A. Infection 3. Answer: C. Drug intoxication.
4. Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate? A. The client is experiencing aphasia. 4. Answer: D. The client is experiencing visual hallucination.
5. Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion? A. The client tries to hit the nurse when vital signs must be taken. 5. Answer: D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.
ReferencesSources and references for this study guide for delirium:
Which nursing intervention helps the family members feel confident in their care of the client when the client is discharged home?Which intervention by the nurse helps the family feel in control when the client is to be discharged home? Instruct the family to ensure the client's room is safe.
How can a nurse best evaluate the effectiveness of communication with a client?How can the nurse evaluate the effectiveness of communication with a client? Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships.
Which is an indirect nursing care intervention?Indirect care intervention is a treatment performed away from the patient, but on his/her behalf or on behalf of a group of patients, where these actions support the overall effectiveness of direct care interventions(5).
What is the priority when the nurse is establishing a therapeutic environment for a client?What is the priority when the nurse is establishing a therapeutic environment for a client? Safety is the priority before any other intervention is provided.
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