Delirium Case Study

Delirium is an unexpected change within the brain that creates a sense of confusion and emotional disturbance. People who have delirium find it difficult to concentrate, remember things, focusing their attention and possible sleep disruption. The condition may present when a person goes through alcohol withdrawal, is recovering from surgery or as dementia. The different kinds of delirium are:

• Delirium Tremens (DT’s) – occur during alcohol withdrawal following severe alcohol addiction.

• Hyperactive Delirium – the client is uncooperative and extremely alert.

• Hypoactive Delirium – is very common, and the client is inactive, sleeps more than normal and becomes disorganized. They may miss scheduled events.

• Mixed – client shows symptoms of both hyper and

hypo that may fluctuate randomly.
Causes
Many things can cause delirium, as long as it affects the chemicals in the brain, the amount of oxygen the brain receives (as with asthma) or viral/bacterial infection. It is important to note, that there is not always a definitive cause that can be identified, but possible causes are:
1. Medications/ drug toxicity 6. Fever or infection
2. Substance abuse 7. Malnutrition
3. Metabolic imbalances 8. Sleep deprivation
4. Chronic or terminal illness 9. Surgery
5. Pain 10. Exposure to toxins
Risk Factors
• 65 years or older.
• Currently have multiple health problems.
• Drug or alcohol withdrawal.
• Stroke or dementia.
• Extreme emotional stress.
• Sleep deprivation.
• Severe dehydration.
• Poor nutrition.
• Infection (UTI)
• Medications (blood pressure drugs, analgesics, sedatives)
Signs & Symptoms
The signs and symptoms often fluctuate during the day, and there can even be periods of little to no symptoms; however, symptoms worsen at night when it is dark and objects and people appear less familiar. The main signs and symptoms are classified below:
[ Emotional ] [ Behavioral ]
• Anxiety or paranoia • Hallucinations
• Depression • Restlessness
• Anger • Lethargy, slowed body movements
• Euphoria • Sleep disruption
• Mood Swings • Unusual sleep-wake cycle
• Personality changes • Calling out, moaning.
[ Reduced awareness of the environment ]
• Inability to maintain focus.
• Being stuck on a thought and not being able to respond to conversation.
• Easily distracted.
• Withdrawn, little interaction with the environment.
[ Cognitive Impairment ]
• Poor memory, especially short term memory.
• Disoriented.
• Difficulty with speaking and remembering words.
• Rambling.
• Trouble reading or understanding spoken words.
Treatment
The primary goal of treatment is to identify and treat the underlying cause(s) and then follow up with a healing environment and heal the brain.
Supportive Care – this is meant to help prevent any complications such as supporting the airway along with cerebral function, administering fluids, treating pain and addressing incontinence issues.
Medications –
• Antidepressants – Paxil (Paroxetine), Prozac (Fluoxetine), Zoloft (Sertraline), Lexapro (Escitalopram) and Celexa (Citalopram)
• Dopamine blockers – Haldol (Haloperidol), Risperidal (Risperidone), (Acepromazine)
• Vitamins – Thiamilate, Biamine (Thiamine Hcl) and Cyomin (Cyanocobalamin) for confusion.
Treatment Goals
The main goals of therapy are to prevent the client from experiencing further complications or any further cognitive impairment. The medications are to help manage confusion symptoms, or for the treatment of other underlying conditions that may be causing the delirium.
Nursing Interventions
1.

Evaluate LOC and mental status. Rationale: determine a baseline for future comparison, along with determining neurologic status.

2. Initiate fall prevention and arrange furniture to accommodate client. Rationale: confusion increases the client’s risk for falls; safety is important.

3. Determine the client’s nutritional status. Rationale: client may have been unable to properly cover their nutritional needs and may be malnourished or have underlying electrolyte imbalances.

4. Frequently orient the client to time and place. Rationale: they may not remember where they are, or what day it is; he or she may be out of touch with reality. May need to use calendars or clocks with large numbers.

5. Keep any explanations simple and short. Rationale: may increase the likelihood they will remember and understand what is being explained. Will also increase client compliance.

6. Assess the client’s ability to perform ADL’s and provide assistance if needed. Rationale: they may be experiencing self care deficit’s and need help to learn how to perform them again.

7. Provide consistency in healthcare members who care for the client. Rationale: will help to reduce client confusion and

disorientation.
8. Use a nightlight during the late hours of the day and at night. Rationale: client safety and reduce the chances of the client tripping over hidden objects or furniture because their visual perceptions become distorted at night.
9. Administer Biamine (Thiamine HCl) as ordered by the doctor for confusion.
• Record client’s dietary history carefully.
• Thiamine requirements increase when diet consists predominantly of carbs.
10. Encourage and assist the client with frequent ambulation. Rationale: avoid blood clots or pressure ulcers; while assistance is for client safety.
11. Involve the family members in helping to care for the client. Rationale: family support will help with the client’s comfort level, as well as helping to educate the family on the client’s condition.
Goals/Outcome
• Client will perform ADL’s to the best of their ability.
• The client will demonstrate increased ability to maintain orientation to their environment and to reality.
• Client will not experience injury.