Question

85 yr old male with a history of HTN, DM, hypothyroidism, and depression presented to the Emergency Department from an ECF with acute change in mental status. Staff at ECF described patient as “confused” “not acting himself” and “incoherent”. He was refusing food, fluid, and medications X 4 days prior to coming to the hospital. He became agitated in the ED requiring sedation with 1 mg of haloperidol – IM. Family not available for collateral information. Prior to receiving haloperidol patient was alert, oriented to person, month, and year. He was not oriented to place, situation, or date/ day of week. Reduced attention and very distracted- often looking from side-to side. On one occasion he commented “did you see those dogs run by”. He was not able to provide a coherent history due to disorganized, illogical thoughts. He thought he was in a “torture chamber” and he was being poisoned. Speech was rambling with avg volume, and at times difficult to comprehend. Unable to test memory. Demonstrates poor insight and judgment. He is admitted to the hospital and placed on a medical hold.

Abnormal Labs: BMP- Na+ 128; CBC- WBC 15,000; UA + nitrites and leuk esterase

EKG- QTc 515

VS: B/P 162/100, P- 112, T- 99.2, R-12

Medications: citalopram 40 mg qd, carvedilol 25 mg bid, hydrochlorothiazide 25 mg qd, metformin - dose not known (does have normal renal function)

1. What are some of the possible causes of delirium? (use the mnemonic I WATCH DEATH)
2. What are the signs and symptoms of delirium in this patient?
3. What are some additional labs/ tests that might be performed?
4. What medications may need to be held with QTc > 500?
5. What are pertinent nursing diagnoses?
6. What are pertinent short- term goals for this patient and diagnoses?
7. What are the most important nursing interventions for this patient?
8. Are there any legal, religious, or spiritual issues?

Answer 1

1. Causes of delirium: (WHHHHIMPS)

* Wernicke encephalopathy.

* Hypoxia

* Hypoglycemia

* Hypertensive encephalopathy

* Hyperthermia or hypothermia.

* Intracerebral hemorrhage.

* Meningitis or encephalitis.

* Poisoning.

* Status epilepticus.

2. Signs and symptoms:

* Fluctuating level of consciousness.

* Disorientation.

* Visual hallucinations.

* Disorganized thought process.

* Incoherent speech.

* Agitated behavior.

* Dehydration.

*Poor memory.

* Poor judgment.

3. Additional lab test:

* Blood glucose level - to rule out hypoglycemia.

* Test for bacteriological and viral etiology.

* Screening of serum marker for delirium - The Calcium- binding protein S-100 could be a serum marker for delirium. High levels are seen among delirium patients.

*CSF analysis - To rule out brain infections.

4. For QTc 500 ms or greater,

* Aripiprazole.

* Valporate.

* Trazodone.

* Benzodiazepines can be administered.

5. Nursing diagnosis:

* Chronic confusion related to cognitive impairment.

* Disturbed thought process related to delusional thought.

* Risk for injury related to suicidal thoughts.

*Fluid volume deficit related to refusal of intake.

* Risk for imbalanced nutrition related to nil per oral.

* Impaired social interaction related yo less social support.

* Impaired speech related to poor thought process.

6. Short term goals:

Client will be able to orient to the environment, maintain agitation at a manageable level so that it will not turn into violence.

Client will not harm self or others.

7. Nursing interventions:

* Maintain low level of stimuli in client's environment like low lighting, low noise, simple decor and limiting visitors...

* Remove all potentially harmful objects from client's environment.

* Maintain calm manner and reassure the client.

* Teach relaxation exercises.

* Diversion therapy helps to modify harmful thoughts.

* Observe for anxiety and help the client to overcome that.

8.Legal, spiritual issues:

Yes, as the client is affected mentally legal and ethical considerations are necessary while attempting to provide care to them. Spiritual support also essential to strengthen the client.