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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. 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 ManagementNursing 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. B. It’s characterized by a slowly evolving onset and lasts about 1 week. C. It’s characterized by a slowly evolving onset and lasts about 1 month. D. It’s characterized by an acute onset and lasts hours to a number of days. 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. D. Inability to perform self-care activities. 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 B. Metabolic acidosis C. Drug intoxication D. Hepatic encephalopathy 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. B. The client is experiencing dysarthria. C. The client is experiencing a flight of ideas. D. The client is experiencing visual hallucination. 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. B. The client says, “I keep hearing a voice telling me to run away.” C. The client becomes anxious whenever the nurse leaves the bedside. D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. 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:
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