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Illusions - THE CORRECT ANSWER-ERRORS IN PERCEPTION OF
SENSORY STIMULI
-may mistake folded blankets for white rats
-cord of window blind for a snake
-stimulus is real, person misinterprets it
-explain and clarify illusions to individual
Delirium assessment - THE CORRECT ANSWER-PERFORM MEDICAL
EVALUATION FIRST
-information from family/friends
-review medication history/drug use
-any underlying illnesses/diseases
-blood work
-urinalysis
-CBC/CRP
-safety/fall risk
,-exit seeking
-assess risk for poly pharmacy (using multiple drugs)
delirium physical needs - THE CORRECT ANSWER-patient becomes
disoriented
-may wander or try and pull out IV lines
-fall out of bed
-want to go home or think hospital is home
-SIMPLE ENVIRONMENT/CLEAR
-Clocks/calendars
-visual/auditory aides
-interact with patient
-poor self care=
delirium assessment guidelines - THE CORRECT ANSWER--dont
assume confusion is bc of dementia
- assess acute onset/fluctuating levels
-assess ability to attend to immediate surroundings including
nursing care
-establish usual LOC
-assess past cog impairment/other risk factors
-identify disturbances/physiological abnormalities
-VS, LOC, neuro signs
-assess potential injury
-maintain comfort measures (pain/cold/positioning)
-mon factors that worsen/improve
,-assess availability of immediate med interventions to help
prevent irreversible brain damage
Mood and behavior of delirium - THE CORRECT ANSWER--change
drastically in short period
-agitation/quiet delirious
-no agitation= hypoactive
-fear/anger/euphoria/depression/apathy
-may strike out in fear and call for help or become calm next
minute
-erratic and fluctuating
Nursing diagnosis delirium - THE CORRECT ANSWER-SAFETY IS
PRIORITY
-risk of injury if felt threatened
-altered perception/hallucinations/delusions
-fever/dehydration= risk for fluid imbalance
Ask exploring questions
-reduced clarity of awareness
-reorient patient
-impaired communication
Planning delirium - THE CORRECT ANSWER-does patient have
necessary visual/hearing aids
-are family members able to stay with patient
-does environment provide visual cues
-has person experienced continuity of care
, Delirium interventions - THE CORRECT ANSWER-SFAETY
-correct underlying disorder
-monitor neuro status
-avoid frustrating patient/quizzing with questions hard to
answer
-administer medications
-monitor fluid and nutrition intake
-assist with daily needs
-physical restraints should be avoided as they cause increase in
agitation
-use family members in care
-Maintain a WELL LIT/ HAZARD FREE environment
-acknowledge fears/feelings
-optimistic but realistic reassurance
-provide information about what is happening/expected
-limit need for decision making (no hard questions, simple
easy)
-accept patients perceptions/interpretations of reality
-reorient patient to time place etc
-APPROACH SLOWLY/FROM THE FRONT
-address patient by name
-always reintroduce self
-simple/direct/descriptive statements
-consistnet environment /daily routine
-clocks/calendars/pictures