Question

Provide one nursing intervention for each risk factor below that would mitigate delirium.

-Dementia

-Polypharmacy

-Infection/dehydration

-Recent surgery

Answer 1

Delirium

Serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings.

It can be triggered by ;

• Infection
• Some Medication / Polypharmacy
• Drug Withdrawal
• Intoxication

Seeking for medical interventions if ,;

• Sees or hears things that other people don't
• Become confused & doesn't know where they are
• No longer recognise the people around them (Dementia)

Nursing intervention Includes ;

Dementia

Nursing diagnosis : Disturbed thought process related to effects of dementia as evidence by loss of memory & other cognitive deficit.

Interventions :

Determine type & extent of cognitive deficit, using standardized assessment tool, to establish baseline function.

Give one simple direction at a time to decrease confusion & frustration

Limit number of choices patient has to make

Polypharmacy

Nursing diagnosis : Drug toxicity or drug interaction / concurrent useof multiple medications manifested by cognitive / functional impairement as evidenced by falls, malaise / abdominal complaints etc

Interventions

Obtain adequate medication & medical history

Link each prescribed medication to the disease state

Reconcile medication upon discharge from health care settings

Infection

Nursing diagnosis :Risk for infection related to malnutrition secondary to memory disfunction.

Intervention

Monitor for systemic & localised signs & symptoms of infection ( eg, pain on urination, hemsturhe, cloudy urine, chills, fever ) to ensure early identification & treatment.

Limit number of vidvisit to reduce the risk of infection

Teach client & family about signs & symptoms of infection & when to report them to the health care provider to obtain early treatment

Recent Surgery

Nursing diagnosis : Pain related to surgical incision as evidenced by verbalization, reluctance to move, guarding of affected area, pain score >8 on 10 point pain scale.

Interventions

Evaluate effectiveness of pain cobtrco measures used through ongoing assessment of pain experience so that Pain relief is in accordance with healing process

Position in proper body alignment to reduce pressure on nerves & tissues