NURSING 2LA2 Lecture Notes - Central Venous Catheter, Morphine, Interleukin 2

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Published on 16 Apr 2013
School
McMaster University
Department
Nursing
Course
NURSING 2LA2
Pathophysiology: Delirium
*Areas in italics are portions dictated throughout module.
*Notes begin on slide #3.
Slide: Delirium
Common, life threatening and potentially preventable clinical syndrome, induced by a variety of
physical causes.
Often defined as an acute decline in the cognitive processes of the brain, namely attention and
cognition.
Most strongly associated with hospitalized patients 65 years of age and older.
Patients with delirium may exhibit periods of inattention, disorganized thinking, changes in LOC,
disorientation, delusions, perceptual disturbances, as well as impaired memory, speech, sleep,
and psychomotor activity.
These changes in cognitive function can fluctuate in severity throughout the day and as such,
delirium is often under-recognized and under-treated.
Estimated that 2/3 of patients go unreported.
This can be attributed to the syndromes fluctuating nature and the wide range of symptoms and
patient characteristics associated with the syndrome.
Some clinicians continue to use the term confusional state or encephalopathy, when diagnosing
delirium, further complicating the proper identification, management and treatment of this life-
threatening syndrome.
Slide: Delirium
As mentioned, delirium frequently accompanies acute illness in hospitalized elderly patients.
Historically, delirium was accepted as a harmless process, however, data collected over the past
15 years has shown that this clinical syndrome is linked to poor clinical outcomes and should be
regarded as a marker for severe illness and mortality.
In North America, delirium complicates the hospital stays of approx. 20% of patients, 65 years of
age and older.
More concerning, is the evidence that the one year mortality rate associated with cases of
delirium in the elderly, is 35-40%.
Current studies investigating delirium and its outcomes suggest that the development of delirium
in the hospitalized elderly initiates a cascade of events that culminate in the loss of a patients
independence, increased risk for morbidity and mortality, and increased health care costs due to
longer hospital stays, rehabilitation, need for formal home health care, or long-term
institutionalized care.
Despite this evidence, it is estimated that only 40% of clinicians routinely screen delirium in
hospitalized elderly patients.
Slide: Diagnostic Criteria for Delirium
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Currently, the DSM-IV defines delirium by the presence of disturbed consciousness and a change
in cognition or the development of a perceptual disturbance that is not better accounted for by a
pre-existing, established or evolving dementia.
This disturbance in consciousness must develop over a short period of time and should fluctuate
over the course of the day.
Moreover, there must be evidence from clinical history, physical examination and/or lab findings
that the disturbance is caused by the physiological consequences of a medical condition.
Slide: Clinical Features of Delirium
Introduction: Characteristics of Delirium
o In addition to the core symptoms outlined by the DSM-IV, the clinical features shown
are also hallmark characteristics of delirium.
Acute Onset:
o Occurs abruptly, usually over a period of hours or days.
o Reliable information often needed to ascertain the time course of onset.
Fluctuating Course:
o Symptoms tend to come and go or increase and decrease in severity over a 24-hour
period
o Characteristic lucid intervals
Inattention:
o Difficulty focusing, sustaining, and shifting attention
o Difficulty maintaining conversation or following commands
Disorganized Thinking:
o Manifested by disorganized or incoherent speech
o Rambling or irrelevant conversation or an unclear or illogical flow of ideas
Altered LOC:
o Clouding of consciousness, with reduced clarity of awareness of the environment
Cognitive Deficits:
o Typically global or multiple deficits in cognition, including disorientation, memory
deficits, and language impairment
Perceptual Disturbances:
o Illusions or hallucinations in about 30 percent of patients
Psychomotor Disturbances:
o Psychomotor variants of delirium
o Hyperactive: marked by agitation and vigilance
o Hypoactive: marked by lethargy, with a markedly decrease level of motor activity
o Mixed
Altered Sleep-Wake Cycles:
o Characteristic sleep-cycle disturbances
o Typically daytime drowsiness, night-time insomnia, fragmented sleep, anxiety,
depression, irritability, apathy, anger, or euphoria
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Emotional Disturbances:
o Common
o Manifested by intermittent and labile symptoms of fear, paranoia, anxiety, depression,
irritability, apathy, anger, or euphoria
Slide: Delirium, Dementia & Depression
While reviewing the clinical features of delirium listed in the previous slide, you may have noticed
that many of the symptoms observed in patients with delirium are also observed in patients with
other neuro-psychiatric diseases or medical illnesses.
This likely represents another reason as to why patients with delirium may be difficult to identify,
especially to an inexperienced health care worker.
Consequently, it is crucial that the health care team perform both a careful and detailed history
and physical examination of the patient to distinguish between delirium and other types of
mental illness or dementia.
As discussed, in cases of delirium, the onset of altered consciousness, cognitive disturbances or
hallucinations, is typically acute and presents in the context of mental illness, surgery, or
medication change.
To the untrained eye, these features can sometimes be mistaken for a psychotic disorder,
especially when auditory or visual hallucinations predominate.
In such cases, it is important to remember that schizophrenia tends to have a gradual onset and
appears in late adolescence and early adulthood; it is also preceded by a phase of social isolation
that lasts weeks to months.
Moreover, disorientation and fluctuations in LOC are rare in schizophrenia but are a hallmark
feature of delirium.
Delirium may also be mistaken for dementia; in patients with dementia the LOC is typically intact
and inattention is either absent or mild when compared to other cognitive deficits.
Patients with dementia rarely exhibit fluctuations in their cognitive function, another
distinguishing feature between dementia and delirium.
Finally, delirium may also be mistaken for depression, especially when the patient’s symptoms
are hypoactive in nature.
Unlike delirium, depression has a more gradual onset of psychomotor slowing and the cognitive
deficits tend to reflect disinterest rather than disorientation commonly seen in patients with
delirium.
Slide: Types of Delirium
Adding to its complexity, delirium exists in three different subtypes: hyperactive, hypoactive and
mixed subtypes.
Hyperactive delirium is often characterized by symptoms of restlessness, constant movement
and agitation, insomnia, hyper-vigilance, irritability, distractibility, rapid speech,
uncooperativeness, and wandering behaviour are also observed.
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Document Summary

*areas in italics are portions dictated throughout module. Common, life threatening and potentially preventable clinical syndrome, induced by a variety of physical causes. Often defined as an acute decline in the cognitive processes of the brain, namely attention and cognition. Most strongly associated with hospitalized patients 65 years of age and older. Patients with delirium may exhibit periods of inattention, disorganized thinking, changes in loc, disorientation, delusions, perceptual disturbances, as well as impaired memory, speech, sleep, and psychomotor activity. These changes in cognitive function can fluctuate in severity throughout the day and as such, delirium is often under-recognized and under-treated. Estimated that 2/3 of patients go unreported. This can be attributed to the syndromes fluctuating nature and the wide range of symptoms and patient characteristics associated with the syndrome. Some clinicians continue to use the term confusional state or encephalopathy, when diagnosing delirium, further complicating the proper identification, management and treatment of this life- threatening syndrome.

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