The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [160]
Box 5.12 Signs and symptoms of delirium
Difficulty maintaining attention on features of the environment.
Easily distractible.
Unable to have a coherent conversation.
Unable to recall recent events.
Other observable features include:
disorientation
rambling speech
disinhibition
slow responses
disturbance of sleep patterns
rapid mood changes or a significant change of attitude
distress
hallucinations and being irrationally frightened of objects.
(Irving and Foreman 2006)
Evidence-based approaches
Nurses play a critical role in the prevention, early detection (Milisen et al. 2005) and management of delirium. Delirium is frequently iatrogenic (i.e. caused by medical intervention) and hence can often be corrected once the causative factor has been identified.
Addressing the causative factors as part of good nursing and medical care will help prevent the development of delirium. This means ensuring hydration and nutritional requirements are met and any electrolyte imbalances are monitored and corrected.
Nurses need to be aware that patients over the age of 65 (especially those having anaesthesia) will be highly prone to developing delirium so need to be monitored carefully over a period of time to pick up any early signs. The effect of analgesia (especially opiates) also needs to be considered.
The emergence of delirium can also be significant at the end of life and significantly complicate care (Delgado-Guay et al. 2008). Terminal restlessness is a term often used to describe this agitated delirium in end-of-life care, where the causes may require specific management different from that of other types of delirium (Travis et al. 2001). A progressive shutdown of body organs in the last 2–3 days of life (Lawlor et al. 2000) leads to irresolvable systemic imbalances. The management of delirium in end-of-life care therefore shift from a focus on reversing the cause to alleviating the symptoms. Nurses should avoid medicating symptoms unless this is in the patient’s best interests.
Principles of care
Initial screening for any cognitive issues on admission is important to identify predictive factors and establish a baseline of cognitive functioning. Involving the family can be crucial to an accurate assessment where there are existing changes.
Once identified, delirium should be managed by attempting to establish the potential reversible causes. This will include:
newly started medications
changes in dosage
opioid toxicity, withdrawal from opioids or alcohol
use of corticosteroids
metabolic imbalances or organ failure affecting the processing and excretion of drugs
infections
hypercalcaemia
constipation.
Legal and professional issues
In the case of medium to longer term delirium, another person may make decisions upon the patient’s behalf – this person will have ‘lasting power of attorney’ and may have been nominated by the patient. It could be a professional, friend or a member of the family. This person will need to be registered with the public guardian and is bound to act in the patient’s best interests.
The Mental Capacity Act sets out protection for liability when caring for someone with reduced capacity. This is reliant upon accurate and suitable assessment of capacity and best interests.
Restraint
Restraint is a difficult ethical issue requiring careful consideration. Restraint takes many forms and must be meticulously judged for the potential to benefit or harm an individual. As a general rule, restraint should be a last resort to protect the individual and/or others from harm.
Wherever possible, nurses must attempt to create an environment where restraint is not going to be necessary. It is a rare requirement and all feasible steps to avoid the use of restraint must be explored.
Any action taken must be the ‘least harmful’ intervention in the circumstance. The aim is to balance the patient’s right to independence with their and others’ safety. If restraint