delirium - transient, reversible cause of mental dyfunction
answer ✅hyper or hypoactive - how can delirium present as?
answer ✅yes - is delirium a medical emergency
answer ✅elderly - what age group is delirium more common in
answer ✅mortality - what does delirium increase in all hospitalized patients
answer ✅Functional decline
Multiple medical comorbidities
Older than 65
Polypharmacy
Poor nutrition/dehydration
Pre-existing cognitive impairment
Sensory impairment
Alcohol or drug withdrawal
Dehydration
Medications: anticholinergics, opioids, sedatives
Pain
Prolonged sleep deprivation
Severe illness (TBI, poly trauma, sepsis, stroke)
Surgery
Tethers: catheters, tubes, restraints
Urinary retention and/or fecal impaction - risk factors for delirium
answer ✅Clouding of consciousness
Difficulty maintaining or shifting attention
Disorientation
Illusions
Hallucinations
Fluctuating levels of consciousness
Dysphasia
Dysarthria
Tremor
Asterixis
Motor abnormalities - clinical manifestations of delirium
answer ✅CAM- ICU assessment - tool that allows non-psychiatric trained clinicians to identify and
recognize delirium early and intervene
answer ✅prevention - whats the best intervention for all patients with delirium
, answer ✅prevention
Treating the underlying cause
Removing devices
Promoting normal sleep/wake cycle
Keeping lights on and patient awake during the day
Sleep hygiene
Treat pain
Nutrition/hydration
Bowel/bladder control - interventions for delirium
answer ✅Nurses are the frontline defense in delirium prevention and management
Nursing has the ability to recognize and intervene with delirium management
Provide direct patient care and education
Implement bundles
QI/PI - nursing implicaitons for delirium
answer ✅25% - what percentage of hospital patietns does delirium occur in
answer ✅50% - what percent of surgical patients does delirium occur in
answer ✅75% - what percent of ICU patients does delirium occur in
answer ✅violent, combative - what can come with hyperactive delirium
answer ✅sleeping - what happens with hypoactive delirium
answer ✅an unpleasant sensory and emotional experience associated with, or resembling that
associated with actual or potential tissue damage - pain definition
answer ✅subjective - is pain subjective or objective
answer ✅occurs from injury or new onset of tissue damage
protective mechanism
increased nervous system activity
temporary, lasts less than 6 months - acute pain
answer ✅lasts longer than the expected period of healing
over 6 months
pain no longer serves a useful purpose
degrades health and function
often associated with depression, anger, fear, socio economic issues, isolation - chronic pain
answer ✅- incisional pain
- pain from broken bones - examples of somatic pain
answer ✅somatic pain - occurs when nerves from skin, tissue, bones, muscle are activated
answer ✅chest pain from an MI
abdominal pain from galstones - examples of visceral pain
answer ✅visceral pain - involves internal organs or body cavity linings
answer ✅pinched nerve in the spine, diabetes - example of neuropathic pain
answer ✅neuropathic pain - occurs from a direct injury to the peripheral nerves, spinal cord, or
brain
,answer ✅kidney - what organ issues cause you to not be able to be on gabapentin
answer ✅- why they are in the hospital
- invasive lines
- tubes and catheters
- procedures
- exacerbation of chronic conditions - what can be causes of pain in the acute care setting
answer ✅Location
Type
Descriptors: sharp, dull, burning
Radiation: does it move?
What makes is worse/better?
Have you done anything for it? - what to ask when assessing pain
answer ✅Self-reporting if able
Easy to understand by the patient
Ease of documentation and re-evaluation
Numeric scales
Faces
CPOT - tools to evaluate pain
answer ✅Can they talk?
Language barrier?
Age?
Confused? - limitations to pain assessment
answer ✅CPOT (critical care pain observation tool) - Pain assessment for intubated patients
answer ✅Heat
Cold
Positioning
Distraction
Meditation - non pharmacologic interventions to pain
answer ✅NSAIDS
Opioids
Nerve blocks
Local anesthetics
NMDA infusions (ketamine) - pharmacologic interventions for pain
answer ✅Decreased LOC
Decreased respiratory drive
Hypotension
Bradycardia - side effects of opioid administration
answer ✅Patient self-report is optimal
Improved vital signs
Improvement in non-verbal signs of pain
Increased mobility - evaluation of pain management
answer ✅Fear of addiction
Fear of physical dependence
Fear of tolerance
Respiratory depression
, Fear of overdosing - common misconceptions by patients and clinicians when it comes to treatment
of pain
answer ✅pain - what do you have to treat before sedation?
answer ✅tachycardia and htn - what vitals can acute pain cause
answer ✅watch the patient - what should you do when giving morphine, especially if that is their
first time taking it?
answer ✅- educate parents
- be mindful of parents speaking for children
- children metabolize medications faster - patient considerations when giving pain medications to
pediatrics
answer ✅- they might need more meds because of tolerance
- assess vitas
- might not want opioids
- talk to them about their pain and how they manage pain - patient considerations with patients that
are opioid tolerant or have substance abuse history
answer ✅procedural sedation - medication that puts patient out, but not enough to need to
intubate
answer ✅colonoscopy, cath lab, wisdom teeth - what are some situations where we might use
procedural sedation
answer ✅- intubation tray
- oxygen
- bag valve mask
- working IV
- pulse oximeter
- tele monitor
- fluids
- crash cart
- capnograpy
- have someone check your work
-know policy - what do you need for safety when doing procedural sedation
answer ✅A, C (check the site and pulses), D - The nurse receives a telephone call from the cardiac
catheterization lab that a patient is being transferred to the unit following a procedure with moderate
sedation. The nurse plan to take which action first on the arrival of the client?
A. Assess the patency of the airway
B. Check tubes or drains for patency
C. Check the dressing to assess for bleeding
D. Assess the vital signs to compare with preoperative measurements
answer ✅code of ethics - Nursing practice structured by codes of ethics and standards that guide
nursing practice to protect the public
Held to this in a court of law
answer ✅international council of nurses code - Nurses responsible for promoting health, preventing
illness, and alleviating suffering
answer ✅ANA code - Dynamic document
Responsibility as a nurse to be aware of this document
answer ✅hyper or hypoactive - how can delirium present as?
answer ✅yes - is delirium a medical emergency
answer ✅elderly - what age group is delirium more common in
answer ✅mortality - what does delirium increase in all hospitalized patients
answer ✅Functional decline
Multiple medical comorbidities
Older than 65
Polypharmacy
Poor nutrition/dehydration
Pre-existing cognitive impairment
Sensory impairment
Alcohol or drug withdrawal
Dehydration
Medications: anticholinergics, opioids, sedatives
Pain
Prolonged sleep deprivation
Severe illness (TBI, poly trauma, sepsis, stroke)
Surgery
Tethers: catheters, tubes, restraints
Urinary retention and/or fecal impaction - risk factors for delirium
answer ✅Clouding of consciousness
Difficulty maintaining or shifting attention
Disorientation
Illusions
Hallucinations
Fluctuating levels of consciousness
Dysphasia
Dysarthria
Tremor
Asterixis
Motor abnormalities - clinical manifestations of delirium
answer ✅CAM- ICU assessment - tool that allows non-psychiatric trained clinicians to identify and
recognize delirium early and intervene
answer ✅prevention - whats the best intervention for all patients with delirium
, answer ✅prevention
Treating the underlying cause
Removing devices
Promoting normal sleep/wake cycle
Keeping lights on and patient awake during the day
Sleep hygiene
Treat pain
Nutrition/hydration
Bowel/bladder control - interventions for delirium
answer ✅Nurses are the frontline defense in delirium prevention and management
Nursing has the ability to recognize and intervene with delirium management
Provide direct patient care and education
Implement bundles
QI/PI - nursing implicaitons for delirium
answer ✅25% - what percentage of hospital patietns does delirium occur in
answer ✅50% - what percent of surgical patients does delirium occur in
answer ✅75% - what percent of ICU patients does delirium occur in
answer ✅violent, combative - what can come with hyperactive delirium
answer ✅sleeping - what happens with hypoactive delirium
answer ✅an unpleasant sensory and emotional experience associated with, or resembling that
associated with actual or potential tissue damage - pain definition
answer ✅subjective - is pain subjective or objective
answer ✅occurs from injury or new onset of tissue damage
protective mechanism
increased nervous system activity
temporary, lasts less than 6 months - acute pain
answer ✅lasts longer than the expected period of healing
over 6 months
pain no longer serves a useful purpose
degrades health and function
often associated with depression, anger, fear, socio economic issues, isolation - chronic pain
answer ✅- incisional pain
- pain from broken bones - examples of somatic pain
answer ✅somatic pain - occurs when nerves from skin, tissue, bones, muscle are activated
answer ✅chest pain from an MI
abdominal pain from galstones - examples of visceral pain
answer ✅visceral pain - involves internal organs or body cavity linings
answer ✅pinched nerve in the spine, diabetes - example of neuropathic pain
answer ✅neuropathic pain - occurs from a direct injury to the peripheral nerves, spinal cord, or
brain
,answer ✅kidney - what organ issues cause you to not be able to be on gabapentin
answer ✅- why they are in the hospital
- invasive lines
- tubes and catheters
- procedures
- exacerbation of chronic conditions - what can be causes of pain in the acute care setting
answer ✅Location
Type
Descriptors: sharp, dull, burning
Radiation: does it move?
What makes is worse/better?
Have you done anything for it? - what to ask when assessing pain
answer ✅Self-reporting if able
Easy to understand by the patient
Ease of documentation and re-evaluation
Numeric scales
Faces
CPOT - tools to evaluate pain
answer ✅Can they talk?
Language barrier?
Age?
Confused? - limitations to pain assessment
answer ✅CPOT (critical care pain observation tool) - Pain assessment for intubated patients
answer ✅Heat
Cold
Positioning
Distraction
Meditation - non pharmacologic interventions to pain
answer ✅NSAIDS
Opioids
Nerve blocks
Local anesthetics
NMDA infusions (ketamine) - pharmacologic interventions for pain
answer ✅Decreased LOC
Decreased respiratory drive
Hypotension
Bradycardia - side effects of opioid administration
answer ✅Patient self-report is optimal
Improved vital signs
Improvement in non-verbal signs of pain
Increased mobility - evaluation of pain management
answer ✅Fear of addiction
Fear of physical dependence
Fear of tolerance
Respiratory depression
, Fear of overdosing - common misconceptions by patients and clinicians when it comes to treatment
of pain
answer ✅pain - what do you have to treat before sedation?
answer ✅tachycardia and htn - what vitals can acute pain cause
answer ✅watch the patient - what should you do when giving morphine, especially if that is their
first time taking it?
answer ✅- educate parents
- be mindful of parents speaking for children
- children metabolize medications faster - patient considerations when giving pain medications to
pediatrics
answer ✅- they might need more meds because of tolerance
- assess vitas
- might not want opioids
- talk to them about their pain and how they manage pain - patient considerations with patients that
are opioid tolerant or have substance abuse history
answer ✅procedural sedation - medication that puts patient out, but not enough to need to
intubate
answer ✅colonoscopy, cath lab, wisdom teeth - what are some situations where we might use
procedural sedation
answer ✅- intubation tray
- oxygen
- bag valve mask
- working IV
- pulse oximeter
- tele monitor
- fluids
- crash cart
- capnograpy
- have someone check your work
-know policy - what do you need for safety when doing procedural sedation
answer ✅A, C (check the site and pulses), D - The nurse receives a telephone call from the cardiac
catheterization lab that a patient is being transferred to the unit following a procedure with moderate
sedation. The nurse plan to take which action first on the arrival of the client?
A. Assess the patency of the airway
B. Check tubes or drains for patency
C. Check the dressing to assess for bleeding
D. Assess the vital signs to compare with preoperative measurements
answer ✅code of ethics - Nursing practice structured by codes of ethics and standards that guide
nursing practice to protect the public
Held to this in a court of law
answer ✅international council of nurses code - Nurses responsible for promoting health, preventing
illness, and alleviating suffering
answer ✅ANA code - Dynamic document
Responsibility as a nurse to be aware of this document
