The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [161]
An example of justified restraint would be use of mittens in a patient recovering from sedation or anaesthesia who is attempting to remove cannula, drains or catheters (behaviour likely to cause them harm). Regular review and documentation are necessary and the mittens should be removed as soon as the potential harm has passed (RCN 2008).
Documentation
Delirium is under-reported in nursing and medical note taking (Irving et al. 2006). Documentation outlining the onset of behaviours and symptoms is instrumental in assisting the medical team to identify the cause and likely solution to the problem. The documentation of the assessment and subsequent care must be detailed and accurate.
Preprocedural considerations
Pharmacological support
Once diagnosed, symptoms that do not respond to non-pharmacological interventions can be treated with prescribed medication: antipsychotics, for example olanzapine, and/or sedatives, for example haloperidol (NICE 2009b). As far as possible, benzodiazepines are avoided as these are associated with delirium BNF 2011. However, they may be used if delirium is caused by alcohol withdrawal.
Use of medication for sedation in the end stages of life needs individual consideration and the family must be involved and communicated with regularly.
It is worth noting that health professionals and family members can mistake the agitation of delirium for symptoms of pain. If opioids are increased as a result, there will be a potential worsening of the delirium (Delgado-Guay et al. 2008).
Non-pharmacological support
Creating an environment conducive to orientation is important wherever possible, for example a quiet well-lit environment, where normal routines take place. Nurses must help patients to maximize their independence through activity as mobilization is seen to assist with orientation (Neville 2006). Nursing interventions include creating a well-lit room with familiar objects, limited staff changes (possibly requiring one-to-one nursing care), reduced noise stimulation and the presence of family or familiar friends.
Liaison with the patient’s family is important so that they understand what is happening and what they can do to help. It must be recognized how distressing it can be to witness or spend time with a delirious member of the family. The family should therefore be given the opportunity to talk about their concerns and be updated with information about the cause and management.
Safety is a priority and patients must be observed carefully to prevent any injury occurring to themselves or others.
Principles table 5.9 Communicating with an individual with delirium
Principle Rationale
It is essential to ensure that aids for visual and hearing impairments are functional and are being used. To maximize ability to communicate normally. E
Adjust environment to promote the patient’s orientation, for example visible clock or calendar, photographs of family. Maintain/promote orientation. E
Background noise should be kept to a minimum. This can be very distracting for the patient. E
The healthcare professional should introduce themselves to the patient (do not assume they remember you). If possible, limit the number of individuals involved in care. Promote consistency and reduce potential for confusion. E
Give simple information in short statements. Use closed questions. Closed questions are less taxing and only require a yes or no answer. E
It is important to give explicit explanation of any procedures or activities carried out with the individual. Maintain respect and dignity. E
Acquired communication disorders
Definitions
Aphasia/dysphasia (terms can be used interchangeably) is an acquired communication disorder that impairs a person’s ability to process language. It does not affect intelligence but does affect how someone uses language. Any injury to the brain has