University:
Del Mar College
Course:
RNSG 1533 | Health Care Concept II
Academic year:

2023
Views:

256

Pages:

1
Author:

Mira Mccall

ACTIVE LEARNING TEMPLATE: System Disorder STUDENT NAME _____________________________________ Delirium DISORDER/DISEASE PROCESS __________________________________________________________ Alterations in Health (Diagnosis) Risk for injury Acute confusion Risk for deficient fluid volume Pathophysiology Related to Client Problem Exact cause is unknown The main contributing factor is impairment of cerebral oxidative metabolism, where the brain gets less oxygen and has problems using it. REVIEW MODULE CHAPTER ___________ Health Promotion and Disease Prevention Avoid substance abuse Keep hydrated Take medications cautiously as many can cause delirium ASSESSMENT SAFETY CONSIDERATIONS Risk Factors Expected Findings Physiological changes, including neurologic, metabolic, and cardiovascular and respiratory diseases. Infections, surgeries, substances use or withdrawal, older age, multiple co-morbidities, severity of disease, polypharmacy, ICU, aphasia, restraint use, and change in the environment. Laboratory Tests CBC Serum electrolytes Blood urea nitrogen Creatinine levels Urinalysis Liver and thyroid function test Rapid onset and short term Impaired memory, judgment, and ability to focus or calculate. Impairments fluctuate throughout the day, disorientation and confusion is ofter worse at night or early in the morning. Personality change is rapid Vital signs can become unstable Hallucinations or illusions may occur Diagnostic Procedures Physical exam Medical and psychological history CAM Neelon-Champagne confusion scale ECG Oxygen saturation X-rays or scans CT and MRI PATIENT-CENTERED CARE Nursing Care Minimize risk factors and promote early detection Protect client from injury Provide a safe and therapeutic environment Minimize restraints Therapeutic Procedures Personal contact through touch and verbal communication Relaxation techniques Music Therapy Massage Remove scatter rugs Provide good lighting Lock up cleaning supplies Remove clutter and maintain a clear wide pathway to walk through Complications Medications Dexmedetomidi ne (Precedex) Short-acting benzodiazepine s (Lorazepam [Ativan]) Low-dose antipsychotics Client Education Educate caregivers on illness and potential outcomes Educate family on reorientation strategies Reassure family that this is an acute illness and client is likely to return to normal mental status Interprofessional Care Drug therapy Physical activity or ROM Comprehensive interventions Illusions Hallucinations Wandering Disorientation Risk for injury Impaired communication Impaired social interaction Sleep deprivation Self-care deficits

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