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 patient is likely to achieve the maximum benefits of cognitive behavioral therapy?The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions.
How did Sullivan view anxiety?He believed that anxiety and other psychiatric symptoms arise in fundamental conflicts between individuals and their human environments and that personality development also takes place by a series of interactions with other people.
What is the underlying premise associated with behavioral therapy?This form of therapy looks to identify and help change potentially self-destructive or unhealthy behaviors. It's based on the idea that all behaviors are learned and that behaviors can be changed. The focus of treatment is often on current problems and how to change them.
Which developmental model would the nurse use when assessing behavior patterns in patients based on age appropriate development quizlet?Erikson's developmental model is an essential component of patient assessment. Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills.
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