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ABSTRACT: The aim of this article was to review the current literature in relation to the nursing of intensive care unit (ICU) delirium. In particular, we discuss the definition and frequency, clinical features, risk factors, the adverse effects associated with instruments for assessing delirium, as well as prevention and nursing for delirium patients. Critically ill patients are at a greater risk of developing delirium, and delirium is a growing problem in the ICU. Most physicians and nurses regarded delirium as an inconvenient problem, both for patient and for personnel. Routine screening of all patients in the ICU for the presence of delirium is crucial to its successful management. Nurses are on the front line to detect, manage, and even prevent ICU delirium.
In the intensive care unit (ICU), patients are at a very high risk for the development of delirium (Palmieri, 2003). Delirium is frequently defined within the literature as a form of agitation in critically ill patients, yet it remains a persistent issue and little has been carried out to rectify and adequately treat the problem (Van Eijk et al., 2009). Delirium has been observed in cardiothoracic surgical patients since the introduction of open-heart surgery in the mid 1950s (Arend & Christensen, 2009). Postcardiotomy delirium usually develops on day 2 after surgery but can also be seen in the ICU, particularly if patients have a longer postoperative ICU stay than anticipated (Arend & Christensen, 2009). Delirium in the ICU was, until recently, referred to as "ICU psychosis" or simply the "ICU syndrome" (Alexander, 2009). Most physicians and nurses regarded delirium as an inconvenient problem, both for patient and for personnel (Martin, Dasta, & Kane-Gill, 2010). Since the end of the previous century, most patients are being sedated in the ICU for shorter periods and less profoundly, and subsequently, delirium appears to be a more commonly observed condition. The Society of Critical Care Medicine clinical practice guidelines for the use of sedatives and analgesics in the critically ill adult recommend routine monitoring of delirium in ICU patients (Balas, 2010).
Anecdotal evidence has revealed a growing number of agitated patients within the critical care case mix. Patients often presenting with disruptive or combative behaviors have the potential to impact on both patient and staff safety (Alexander, 2009). Staff morale is also affected because of reduced job satisfaction experienced when attempts to deliver high standards of patient care are thwarted by the agitated and perceived noncompliant patient (Spiller & Keen, 2006). The purpose of this article was to review the current discourse in relation to the nursing of ICU delirium. In particular, it will discuss the definition and frequency, clinical features, risk factors, the adverse effects associated with instruments for assessing delirium, as well as prevention and nursing for delirium patients.
Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function. It is characterized by the inability to pay attention, disorientation, the inability to think clearly, and fluctuations in the level of alertness (Van Eijk et al., 2009). Delirium is highly prevalent in hospitalized patients and is reported to occur in 20%-50% of nonintubated ICU patients and in 60%-80% of patients receiving mechanical ventilation (Inouye, 1994). Units that do not actively screen for delirium can miss 60%-80% of cases (Gaudreau, Gagnon, Harel, & Roy, 2005). Patients who experience delirium have increased rates of reintubation and mortality, as well as higher hospital care costs (Schofield, Tolson, & Fleming, 2012).
Despite the importance of detecting delirium to prevent negative consequences for patients, two published surveys show a low rate of routine monitoring for delirium (Devlin et al., 2008; Ely et al., 2004).
Delirium is characterized by a cluster of symptoms not all of which are seen in all the patients. However, the symptoms in adults across the age range are comparable. Delirium is described as either hyperactive or hypoactive on the basis of the patients' psychomotor behavior, as shown in Table 1. Agitation, disorientation, delusions, or hallucinations are characteristically observed in the patient with hyperactive delirium. Patients with hypoalert-hypoactive delirium present with differing signs and symptoms to those with hyperalert-hyperactive delirium (Alexander, 2009). Hypoactive delirium is often characterized by withdrawal, lethargy, apathy, quietly confused, and, at times, total lack of responsiveness (Reich, Rohn, & Lefevre, 2010). Patients with hypoactive delirium can often be misdiagnosed with depression; however, delirious ICU patients present with signs of disorientation not observed in depression (Winkler et al., 2011).
Although various studies report different frequencies of occurrence of individual symptoms, certain symptoms occur more frequently than others (attention deficits, sleep-awake cycle disturbance, and motor activity changes) are described as the "core" symptoms of delirium, whereas other features are more variable in presentation (psychosis, mood changes, etc.; Meagher, 2001). Table 1 lists the various clinical features encountered in the two kinds of delirium and also the commonly corresponding indicators (Granberg, Engberg, & Lundberg, 1996). In addition, according to the activity and psychomotor behavior, a third subtype has been described-mixed delirium. The mixed subtype of delirium is characterized by often unpredictable fluctuations between the hyperactive and hypoactive subtypes.
The pathophysiology of ICU delirium is not well understood (Justic, 2000; Van Eijk, Kesecioglu, & Slooter, 2008; Winkler et al., 2011). It is thought to be multifactorial, and many theories have been postulated including a local inflammatory response of the brain to insult, such as infection, resulting in alterations in neuronal activity; reduced cerebral perfusion; imbalances in the neurotransmitters modulating cognition, with predominately a relative excess of dopamine in relation to acetylcholine; and metabolic derangements (Pun & Boehm, 2011; Van Eijk et al., 2008). Limited researches have been conducted to determine risk factors for the development of ICU delirium. In addition, those that have been conducted cannot prove definitive causality and, at times, have discordant findings. Nevertheless, bedside caregiver should assess patients daily for risk factors to help facilitate delirium prevention. Prior cognitive impairment, old age, fracture on admission, symptomatic infection, some narcotic use, and male gender were independently associated with delirium. A list of risk factors that have been identified in the literature as well as those that have been extrapolated from non-ICU populations is presented in Table 2 (Arend & Christensen, 2009; Inouye, 1994).
The aging population has led to an increase in the number of elderly patients being cared for in the ICU. This has caused an escalation in the prevalence of delirium, which has increased proportionately with illness severity (Van Eijk et al., 2008). The literature documents a diverse range of adverse effects of delirium, which can affect patients, healthcare professionals assigned to their care, and significant others (Van Eijk et al., 2008). Hypoactive delirium is associated with the worst clinical prognosis of all types of delirium (Irving & Foreman, 2006). These patients are at a greater risk of extended periods of mechanical ventilation and associated complications, such as aspiration, nosocomial pneumonia, decubitus ulcers, and venous thromboembolic disease (Seeling & Heymann, 2009).
In contrast, the behaviors of patients with hyperactive delirium are more typically disruptive with disordered thinking and fear-like symptoms, which often result in the refusal of care and the exhibition of disruptive behaviors (Devlin et al., 2008). Typically, this state of delirium alters the ICU patients' mental status to such an extent that they cannot appreciate the purpose of therapies required to treat their critical illness (Jackson et al., 2011). Although not done purposely, this places these particular patients in danger through self-removal or disruption of monitoring devices with possible disastrous consequences (Hewitt, 2002). Like hypoalert-hypoactive delirium, hyperalert-hyperactive delirious patients may also be at similar risks to those mentioned above should they be sedated to control their behaviors (Park et al., 2009). However, with the agitation and disruptive behaviors associated with this subtype of delirium, other detrimental sequelae can often occur, for example, dysynchrony with mechanical ventilation, acute myocardial stress (increases in heart rate, blood pressure, cardiac contractility, afterload, dysrhythmias, and myocardial oxygen consumption), and cerebral ischemia (Park et al., 2009). There is also concern that, in attempts to manage patient safety, there will be a delay in evaluating and treating acute metabolic, toxic, or neurological abnormalities, which may be causing the delirium initially (Park et al., 2009). The confusion and agitation can be exhausting for the patient and have a negative effect on patient comfort (Marshall & Soucy, 2003).
In addition, long-term consequences can occur, and patients who have experienced delirium may be predisposed to prolonged neuropsychological deficits, all of which combine to increase mortality, morbidity, and length of stay (Jackson et al., 2011). The cognitive impairment of delirious patients may result in their misperceiving the environment as hostile or threatening (Seeling & Heymann, 2009). This can manifest behaviors, which pose safety risks for staff as well as the patients, such as combativeness, shouting, hitting, scratching, and climbing out of bed (Van Eijk et al., 2008). It is has been documented that many healthcare professionals experience trepidation and disquiet when confronted with the care of restless and agitated patients in the ICU (Alexander, 2009). Although the effects of delirium have a significant impact on the ICU patient, it is the associated behaviors that often contributes to the stress of family and friends, and this may affect their satisfaction with healthcare delivery (Van Eijk et al., 2008). It may also cause embarrassment at the inappropriate or unhelpful actions of their loved one, and the disruptive behavior may cause great distress to significant others who knew the patient as a lucid and rational beings, only hours earlier (Martin et al., 2010).
Various tools have been developed for standardized delirium testing by ICU nurses. In 2004, Ely found that only 40% of 912 surveyed critical care professionals monitored for delirium and only 16% used a specific tool (Ely et al., 2004). In a recent survey of 331 ICU nurses in hospitals where delirium assessment is required, only 47% of nurses reported performing this assessment (Luetz et al., 2010). These nurses used six different methods for assessing ICU delirium: patient ability to follow commands (78%), agitated related events (71%), the Confusion Assessment Method for the ICU (CAM-ICU; 36%), Intensive Care Delirium Screening Checklist (ICDSC; 11%), psychiatry consult (9%), and the Clinical Institute Withdrawal of Alcohol Scale-Revised (7%; Sona, 2009). Forty percent of respondents were unsure of their unit protocol or felt that the delirium assessment was not clearly specified (Sona, 2009). Of the above-mentioned methods for the assessment of delirium, five tools are specifically designed for use in the ICU: the CAM-ICU, the NEECHAM, the Nursing Delirium Screening Scale (Nu-DESC), the Delirium Detection Score (DDS), and the ICDSC.
The CAM-ICU (Luetz et al., 2010), developed by Inouye, is based on psychiatric expert and delirium definitions of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; Inouye, 1994) to assess delirium by nonpsychiatrists. The CAM has proven to be easy to use, reliable, and valid; it was first used in the early 1990s (Inouye, 1994). The CAM addresses the following four features: (a) an acute onset of mental status change or fluctuating course, (b) inattention, (c) disorganized thinking, and (d) altered level of consciousness.
The CAM had limited utility in the ICU because of the inability for use in patients who were nonverbal and/or who received mechanical ventilation (Ely, Siegel, & Inouye, 2001). The CAM-ICU modified the validated CAM for use in those patients by using nonverbal, objective instruments. The CAM-ICU begins with an arousal/sedation assessment incorporating the use of the validated Richmond Agitation and Sedation Scale (RASS). When patients are found to be deeply sedated or unconscious using the RASS (RASS -4 and -5), the assessment for delirium is stopped until the patient is responsive to voice. These levels are referred to as coma or stupor (Ely et al., 2003), and in those situations, it is difficult to assess delirium because patients are not responsive. However, at the lighter levels of consciousness (RASS -3 through +4), patients are able to display at least the beginnings of meaningful responsiveness (Sessler et al., 2002). At these levels, CAM-ICU could be conducted to assess delirium.
To be diagnosed as delirious (CAM-ICU positive), the participant must display features 1 and 2 and either 3 or 4. The CAM- ICU had high interrater reliability and specificity in the original validation study, including adults in medical and coronary ICU (Jeffrey, Bruno, & Warren, 2010). For the CAM-ICU, 95% sensitivity and 98% specificity have been described (Jeffrey et al., 2010).
The advantages of CAM-ICU include a short time for scoring (2-5 minutes per patient) and its high reliability. The most important contribution of the CAM-ICU is that it does not depend on the patient being able to talk verbally to assess the delirium. Thus, the CAM-ICU has the advantages in use for those patients who cannot express himself or herself with endotracheal tubes. But the CAM-ICU needs a short visual or auditory test, and this made it difficult to use. By contrast, those instruments that depend on symptom and sign score could be popular. In addition, CAM-ICU was a point in time assessment, and therefore, because of the fluctuating nature of delirium, it is hard to monitor the continuous situation of patients.
This instrument contains nine items organized in three domains, with a total possible score ranging from 0 to 30. A total score of 19 or less indicates moderate to severe confusion, 20-24 indicates mild or early developing confusion, 25-26 indicates not confused but with a high risk of confusion, and 27-30 indicates not confused or normal function (Neelon, Champagne, Carlson, & Funk, 1997). The reliability and validity of NEECHAM scale ranged from .67 to .91 for the processing behavior items, whereas the correlations for the vital function and oxygen items were .32 and .37 (Neelon et al., 1997). The interrater reliability of staff nurses trained to use the NEECHAM was .91, and all inter-item correlations were positive and significantly different from zero (Neelon et al., 1997). There was a high positive correlation with the Mini-Mental State Examination (r = .87) and a high negative correlation with the sum of DSM-III-R positive items (r = .86 or .91; Van Rompaey et al., 2008).
NEECHAM is an instrument for assessing acute confusion in hospitalized patients, particularly in the early stages. The scale can be scored with data derived during routine clinical assessments of acutely ill patients. The scale detects changes in severity of acute confusion, and testing can be repeated at frequent intervals.
Data needed to score the NEECHAM can be collected during 10 minutes of routine patient observation and vital sign assessment (Csokasy, 1999). For example, in scoring item 1 (attention/alertness), nurses are asked to observe the patient's immediate responsiveness to events or cues (whether the patient responds appropriately by focusing head/eyes when the nurse enters the room or approaches the bedside or by some recognition of the nurse's role, etc.). Patients with impaired arousal may not respond to the verbal commands of item 2 (complex command processing) but may respond to visually or physically cued commands, such as showing a cup of fluid or touching a cup to the lips while asking the patient to drink. Accurate scoring of the NEECHAM requires an awareness of physical disabilities (visual, hearing, motor, etc.) that affect the patient's mode of responding to signals (Csokasy, 1999). Eye movements, facial expressions, or responses to touch could offer acceptable alternative data for scoring.
The NEECHAM scale was developed as a nursing screening and not as a diagnostic tool. This instrument uses the daily observation skills of nurses and their standard 24-hour monitoring of patient in the ICU. It could enable nurses to recognize a possible delirium in an early stage so that the treatment is possible and the behavior could be prevented. This scale showed acceptable sensitivity, specificity, and predictive values. But the NEECHAM is not easy to use; it comprises three levels including nine items, and it might lead to misunderstanding for bedside nurses because of its complexity. It can only assess those who could verbally express themselves and cannot evaluate the intubated or sedated patients.
The Nu-DESC developed by Gaudreau, Gagnon, Harel, Tremblay, and Roy (2005) is a delirium screening instrument that can be easily integrated into routine care and clinical practice. This scoring system is largely based on the Confusion Rating Scale. However, the Nu-DESC is a five-item scale comprising, in addition to the four items of the Confusion Rating Scale, a fifth item (Lutz et al., 2008). The addition of psychomotor retardation as the fifth major component, as well as several other subcomponents of the Nu-DESC scoring system, gave it some resemblance of the DSM-IV. The fifth item, rating unusual psychomotor retardation, took into account medical condition (delayed responsiveness and few or no spontaneous actions/words; e.g., when the patient is prodded, reaction is deferred and/or the patient is unarousable). This brings the maximal screening score to 10 (Luetz et al., 2010). The Nu-DESC has the sensitivity of .86 and a specificity of .87 for detecting delirium (Gaudreau, Gagnon, Harel, & Roy, 2005).
The Nu-DESC comprises only five items, so it is easy to use, time-efficient, and accurate and could lead to prompt delirium recognition and treatment. The Nu-DESC shows promise as a useful concomitant delirium assessment tool, allowing continuous screening and symptom monitoring. It is an observational screening tool for delirium, which requires no direct patient participation and can be administered by registered nurses in only 1-2 minutes.
The DDS is modified from the CIWA-Ar to ICU needs and is composed of eight criteria: agitation, anxiety, hallucination, orientation, seizures, tremor, paroxysmal sweating, and altered sleep-wake rhythm. For each criterion, 0, 1, 4, or 7 points can be allocated depending on the symptoms (e.g., orientation: 0 = orientated to time, place, and personal identity, able to concentrate; 1 = not sure about time and/or place, not able to concentrate; 4 = not orientated to time and/or place; 7 = not orientated to time, place, and personal identity; Luetz et al., 2010). A total of 56 points are possible. Compared with the CIWA-Ar, in the DDS, hallucinations account for only a maximum of 7 points. Following intubation sensations (see items tactile, auditory, and visual disturbance of the CIWA-Ar), accounting for a maximum of 21 points of 67 of the CIWA-Ar would have to be set to "0" because in this incidence it is often hardly possible to diagnose hallucinations. The sensitivity and specificity of DDS were 69% and 75% (Otter et al., 2005). The intraclass coefficient of DDS was .742. The intraclass coefficients for the groups medical doctor-nurse and nurse-nurse were .758 and .642, respectively (Radtke et al., 2008).
Analysis of consecutive measurements showed that the DDS can detect symptoms of delirium, and that can help track and assess treatment (Radtke et al., 2008). However, delirium was detected by the DDS at the same time as the clinical diagnosis of delirium was established. The DDS is composed of several criteria (agitation, anxiety, orientation, and so on). Therefore, the DDS helps to start a symptom-guided therapy immediately and give benzodiazepines for agitation, neuroleptics such as haloperidol for hallucinations, and [alpha]-2-agonists for autonomic signs.
The DDS is an instrument adaptable to detect severe delirium. It takes into account several criteria to assess the severity of delirium. Furthermore, it might help to start a symptom-guided therapy plan easily and immediately. Thus, the DDS could help to guide the management of the delirious ICU patients and is predictive for medication use. However, the result of one study (Radtke et al., 2008) showed DDS with low sensitivity. The reason might be that the DDS looks for agitation but not psychomotor retardation, whereas the hypoactive form of delirium is much more frequent than the hyperactive state.
The ICDSC was an eight-item check list scale, which was developed based on DSM-IV criteria features of delirium (Bergeron, Dubois, Dumont, Dial, & Skrobik, 2001). The first four screening elements directly refer to the first two DSM-IV criteria. The ICDSC combined routinely collected data (such as orientation with short observations) of obvious manifestations of described features. Obvious manifestations of a checklist item during the evaluation period scored 1 point. Any item that could not be assessed was not eliminated but scored no point. The high sensitivity (99%) was shown in the developing ICDSC research (Bergeron et al., 2001). The specificity of the scale was 64%. In other words, a score of 4 points or more will detect 99% of patients who will go on to have a diagnosis of delirium but also falsely identify 36% of patients in whom a psychiatric assessment will not result in this diagnosis (Plaschke et al., 2008).
The ICDSC scoring system is a user-friendly checklist implemented over a 24-hour observer interval, which may be useful in early and systematic screening of delirium in the ICU. It has the following advantages: ease of administration of the instrument; high sensitivity; reliability; the speed in which the questionnaire can be completed; and the fact that many items can be judged by nurses in the process of daily nursing care, which makes it feasible for testing in the ICU setting. After a short training period, it is easy for both nurses and physicians to use at the bedside. It can be applied in a short time to all ICU patients and utilizes as many elements as possible from bedside-collected ICU data. Therefore, the first-line nurses prefer this scale more. However, the specificity of the ICDSC is quite poor.
Inadequate treatment of delirium leads to considerable hazards for the patients, such as dislocation of tubes and catheters by the agitated patient, prolonged mechanical ventilation due to lack of patient compliance during the weaning phase resulting in arrhythmias, or prolonged or even deeper sedation with subsequent pneumonia (Irving & Foreman, 2006). Therefore, management and nursing of delirium is of much importance.
Most published recommendations for delirium treatment in the ICU are empiric. Antipsychotic administration is broadly accepted, especially for agitated delirium (Stepkovitch, Heagle Bahn, & Gupta, 2008). Haloperidol is the mainstay of delirium management as recommended by the Society of Critical Care Medicine due to extensive clinical experience with this medication despite the lack of placebo-controlled clinical trials (Han & Kim, 2004). Haloperidol is a typical antipsychotic that blocks D2 dopamine receptors resulting in amelioration of hallucinations, delusions, and unstructured thought patterns. The onset of intravenous haloperidol is approximately 60 minutes, and the elimination half life is between 10 and 36 hours. Haloperidol is metabolized extensively through the liver and does produce an active metabolite.
Current data supporting the use of haloperidol for ICU delirium is largely based on one retrospective review of a mixed ICU population (Milbrandt et al., 2005). In this study, 83 patients who received haloperidol and 906 patients who had no haloperidol were selected as objects, and a total of 989 patients who remained mechanically ventilated for greater than 48 hours were evaluated for mortality, duration of mechanical ventilation, and length of stay in ICU. The average dose of haloperidol was 11.5 mg/day for 3.5 days. The outcomes showed that there were no differences in the duration of mechanical ventilation and the length of stay in ICU, but haloperidol use was associated with a significant decrease in hospital mortality compared with the nonhaloperidol group.
More recently, a trial prospectively evaluated the efficacy of haloperidol for ICU delirium management in comparison with placebo (Pun & Boehm, 2011). The use of haloperidol was not found to improve the number of days alive without delirium, nor did it increase ventilator-free days, or mortality. Authors concluded that the small sample size may contribute to the negative findings.
Haloperidol has been shown effective from many studies in the treatment of delirium; however, its usage is often limited by safety concerns. Major concerns with haloperidol include extrapyramidal side effects, QT prolongation, and neuroleptic malignant syndrome. Data have suggested that the incidence of extrapyramidal side effects is lower with intravenous compared with oral administration and is likely associated with prolonged use (Stepkovitch, Heagle Bahn, & Gupta, 2008). QT prolongation is generally dose related; however, it has been reported with doses as low as 30 mg/day (Stepkovitch, Heagle Bahn, & Gupta, 2008).
Atypical antipsychotics such as quetiapine have been shown to have equivalent success in the treatment of delirium with haloperidol while being associated with fewer side effects. Several studies have examined the role of atypical antipsychotics for delirium management in various populations. Devlin et al. (2010) conducted a randomized, double-blind, placebo-controlled trial evaluating the efficacy and safety of quetiapine. Therapy was initiated at 50 mg every 12 hours and was titrated upwards by increments of 50 mg every 12 hours to a maximum dose of 200 mg every 12 hours. More than 70% of the study population was medical ICU patients. Quetiapine resulted in a faster resolution of delirium compared with placebo, but no significant differences in duration of mechanical ventilation, ICU and hospital length of stay, or mortality. Results from this study suggest that quetiapine may be considered as an add-on therapy to haloperidol.
Brown and Boyle (2002) suggest that environmental factors, such as social isolation and sensory deprivation, and being moved to a new environment contribute to delirium. Therefore, while in hospital it should be recognized that patients are at increased risk of developing delirium by being moved to a different unit or clinical environment, especially critical severe patients (McGuire, Basten, Ryan, & Gallagher, 2010). This misinterpretation of their health needs often results in them being moved from one area to another more readily than their younger counterparts (Schofield, 2002), thereby increasing the risk of developing delirium.
The patient's environment should be quiet and well lit, with the addition of night lights to reduce misperceptions of the environment and objects contained in the environment (Dahike & Phinney, 2008). It is also thought to be beneficial if the room temperature is maintained between 21.1[degrees]C and 23.8[degrees]C (Dahike & Phinney, 2008). It may be necessary to check the environment for objects that can be misinterpreted by the patient (Schreier, 2010). However, it is important to create a balance between a safe environment and a depersonalized one.
When considering a safe environment for patients in the hospital, it is important to consider the use of prescribed medications. Nurses need to be aware of the risks of delirium associated with medications. Prescribed drugs are implicated in up to 40% of patients who become delirious and should always be considered a factor in the development of delirium (Girard et al., 2010; McCarthy, 2003). McCusker, Cole, Dendukuri, and Belzile (2003) suggested that the number of drugs prescribed should be reviewed often and minimized where possible.
One study took an approach to management of delirium and identified a particular unit with the mission for improving hospital outcomes for delirium. It focused on the process of caring for patients from admission to discharge (Neville, 2006). The interventions were multidisciplinary and again had, in common with previously mentioned approaches, use of guidelines for nurses and physicians and education of the whole team in aspects of delirium identification and treatment. This approach led to less drug use, increased prevention of delirium, and budgetary savings. However, the numbers of delirious patients are large, so a small clinical area will not be able to contain the problem. We do not recommend the interventions like this because it is hard and cruel for nurses to only care patients with delirium or with high risk of delirium in one specialized clinical area or unit.
Nurses need to become more proactive in managing the environment for the benefit of patients. Many supportive measures, including attention to noise reduction and lighting, protect against delirium and should be routinely applied to all patient care settings (Schreier, 2010). Provision of photographs, pictures, calendars, television, newspapers, and radio will help patients to relax and provide orientation or assist in reorientating patients to new environments (Devlin, Bhat, Roberts, & Skrobik, 2011).
Multidisciplinary team work has at times been referred to as "a hardening of the categories" or a territorialism about who is responsible for segments of patient care. What is called for here is much more collaborative. This is important as research clearly demonstrates the value of many disciplines in the management of delirium (Hunter & Cyr, 2006). Education for team members is a common trait of all successful interventions but where this education is followed up with continuing support at a unit level that it has been most successful.
Reliance solely on in-service education, although important, is probably not enough. Implications for undergraduate medical and nursing curricula are also important: Delirium is widespread and will be encountered during undergraduate education and after graduation (Hunter & Cyr, 2006). Nurses and doctors need the skills to work with these patients at risk of or experiencing delirium. It is likely that, to improve care of the patient who is at risk or has delirium, staff will need more than education and training. A research indicated that practices regarding delirium are deep routed and require a change in attitude, knowledge, and skills, which may need to be supported by changes in staff ratios and clinical guidelines (Hunter & Cyr, 2006).
Quality communication is essential for patients at risk of developing delirium, and nurses need to consider how they communicate with all patients. To begin with, it is useful to assess the level of sensory impairment, as this has been implicated in the development of delirium. Parikh and Chung suggest that detection of sensory or perceptual deficits should be incorporated in the initial nursing assessment (Parikh & Chung, 1995).
A number of authors have identified the importance of the presence of relatives in the orientation and reorientation process (Hunter & Cyr, 2006; Parikh, 1995). Meagher (2001) described the importance of the presence of relatives as contributing to a heightened sense of control for patients during their delirious episode by encouraging feelings of security and orientation. Nurses should be welcoming and encourage close family members to be with ICU patients to provide support. However, the nurse will need to explain to relatives why a patient may be delirious, as it can be frightening for the family member or relative if they do not understand.
In fact, more than 60% of patients surviving ICU admission report poor sleep or being sleep deprived (Meagher, 2001). The relationship between sleep deprivation and delirium has been studied for many years. Studies conducted with cardiac surgical patients suggest that sleep deprivation is a result of delirium. So rather than to depend solely on the use of pharmacological agents to induce and maintain sleep in ICU patients, it may prove more beneficial to adopt a less orthodox approach to sleep impairment. McLafferty and Farley (2007) suggested the following strategies to allow maximum periods of uninterrupted sleep. These include using single rooms to aid rest, reducing exposure to multiple sensory experiences, and arranging treatments to prevent constant interruptions to the patient.
Schofield (2002) also suggested that minimizing noise at night might help to ensure uninterrupted sleep, and this was supported by Potter (2004). They also suggest the use of a back massage to relieve stress, the use of relaxation music, and warm milk before going to sleep. Another useful strategy is to try to encourage the patient to engage in as many "typical" presleep rituals as he or she would at home. This can be aided by the use of night lights instead of bright overhead lights and the wearing of night clothes.
Keeping an eye on the patient was important for nurses because they used the information gained from observation to determine whether they needed to intervene to settle the patient down. Nurses spoke at length about how they controlled or managed patients who were at risk for delirium. Their rationale for intervening included ensuring the patients received their therapy, preventing injury, and controlling a situation in which behavior might escalate. For example, "If somebody could sit with them, you don't have to sedate them as much." However, having someone available to sit with an ICU patient with delirium was often a challenge (Bassett, 2010).
Delirium is an independent predictor of higher 6-month mortality, increased cost, and longer stay even after adjusting coma and sedative/analgesic medications. Critically ill patients are at great risk for the development of ICU delirium. With more than 8 of 10 ventilated patients experiencing delirium, this is one of the most frequent forms of organ dysfunction experienced by critically ill patients (Brown & Boyle, 2002). But to our knowledge, no study has yet made a comprehensive review to summarize the related knowledge of ICU delirium. Further research is needed to focus on the onset of delirium, the precipitating risk factors, and the nursing methods in the studied ICU. Thus, the specific aims of this study is to make a review about the incidence, assessing instruments, the management, and nursing care of ICU delirium.
There are several approaches to management of delirium and nursing care interventions focusing on maintaining the safe environment, education for ICU delirium, communicating with patients and relatives frequently and effectively, improving sleep quality, and controlling the situation. Nurses stay with patients day and night; thus, they could monitor patients' condition changes easily. Therefore, bedside nurses in the ICU are the key in achieving improved delirium outcomes for patients. Because of its high incidence rate, ICU delirium deserves enough concern by physicians and nurses. It is important that delirium is detected, diagnosed, and treated early without delay. This may improve patient outcomes and reduce the complications and severity of any associated underlying illness.
Delirium is one of the most common conditions encountered by doctors and nurses in an ICU, yet it remains among the least recognized and understood. Although delirium risk factors are well known and the condition may be preventable in many patients, this has not, for the most part, been translated into concrete action at the unit level. The poor understanding of delirium by staff stems from a historically low educational emphasis on delirium in medical and nursing schools. Moreover, the "intangible costs" of nursing morale and job satisfaction may be reduced when attempts to deliver high-quality patient care are thwarted by the agitation of the patient. Simply, what is really needed is a change in hospital culture and evidence-based strategies. Increasing awareness of delirium among medical and nursing staff seems to be an effective strategy in preventing delirium.
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