Why Are Nurses Confused

Delirium: Why Are Nurses Confused? Nidsa D. Baker

Helen M. Taggart Anita Nivens

Paula Tillman

Nurses have a key role in detection of delirium, yet this condition remains under recognized and poorly managed. The aim of this study was to explore nurses’ knowledge of delirium-related infor­ mation as well as their perception of their level of knowledge.

D elirium is a serious, costly, potentially preventable com­plication for hospitalized patients age 65 and older (Wofford & Vacchiano, 2011). This acute, short­ term disturbance of consciousness may last from a few hours to as long as a few months. It is characterized by an acute onset of inattention, dis­ organized thinking, and/or altered level of consciousness.

Delirium can be categorized as hyperactive, hypoactive, or mixed based on symptoms that can fluctu­ ate and change during the course of the disorder. Hyperactive or excited delirium involves agitation and hal­ lucinations (American Psychiatric Association, 2011; Holly, Cantwell, & Jadotte, 2012). Patients with hyperactive delirium are more likely to receive earlier treatment than patients who exhibit the less easily recognized signs of hypoactive deliri­ um: lethargy, drowsiness, and inat­ tention. In addition, patients may show signs of both hyperactive and hypoactive delirium in a condition described as mixed variant delirium (Holly et al., 2012). Health care providers often confuse delirium with depression and/or dementia (Fick, Hodo, & Lawrence, 2007; Holly et al., 2012; Voyer, Richard, Doucet, Danjou, & Carmichael, 2008). Unlike delirium, which hap­ pens suddenly over a few hours or days, dementia usually develops gradually over months or years, while depression generally develops over weeks or months, or, less often, after a sudden event (Holly et al., 2012; Young & Inouye, 2007) (see Table 1).

Delirium is a common multifac­ torial disorder that involves a vul­ nerable patient with predisposing

factors and exposure to precipitat­ ing factors (Sendelbach & Guthrie, 2009). It can occur at various ages. However, older adults are particu­ larly vulnerable to delirium, espec­ ially when they are ill (Featherstone & Hopton, 2010) (see Table 2). Underlying risk factors are often contributory to delirium in older adults. Common triggers are infec­ tion, medications, general pain, constipation, dehydration, and environmental factors (Dahlke & Phinney, 2008; Quinlan et al., 2011). Although delirium occurs commonly in acute care settings, older adult residents of long-term care and assisted living homes are vulnerable as well. Rates of delirium in long-term care settings range from 1% to 60% (Lee, Ha, Lee, Kang, & Koo, 2011; Siddiqi, Young, & Cheater, 2008). Delirium is asso­ ciated with poor patient outcomes that include longer hospital stays, increased costs, increased need for

post-acute care, and significant stress for patients and families (O’Mahony, Murthy, Akunne, & Young, 2011). At least 20% of the 12.5 million patients age 65 or older hospitalized each year have deliri­ um as a complication, causing a $9,000 to $15,000 increase depend­ ing on the severity in hospital costs per patient. Delirium attributes to annual estimated cost of $38 – $152 billion (Kalish, Gillham, & Unwin, 2014; Young & Inouye, 2007).

The prevalence of delirium varies from 1% to 80% depending on pop­ ulation, the time of delirium assess­ ment, and the assessment method. In addition, the documented inci­ dence of delirium extended from 3% to 61% (Kalish et al., 2014; Young & Inouye, 2007). Addition­ ally, the prevalence of this condi­ tion reported in medical and surgi­ cal intensive care unit cohort stud­ ies varied from 20% to 80% (Girard, Panharipande, & Ely, 2008; Kalish

Nidsa D. Baker, MSN, RN, ANP-BC, is Adult Nurse Practitioner, St. Joseph’s/Candler Health System St. Mary’s Health Center, Savannah, GA.

Helen M. Taggart, PhD, RN, ACNS-BC, is Professor, Department of Nursing, College of Health Professions, Armstrong Atlantic State University, Savannah, GA.

Anita Nivens, PhD, RN, FNP-BC, is Graduate Nursing Program Coordinator and Professor, Department of Nursing, College of Health Professions, Armstrong Atlantic State University, Savannah, GA.

Paula Tillman, DNP RN, ACNS-BC, is Assistant Professor, Armstrong Atlantic State University, Savannah, GA, and Informatics Specialist, Memorial Health University Medical Center, Savannah, GA.

Acknowledgments: The authors thank Malcolm Hare, Fremantle Hospital and Health Service and Curtin University School of Nursing in Australia, for granting permission to utilize the ques­ tionnaire.

MEDSURG n u r s in g . January-February 2015 • Vol. 24/No. 1 15

Research for Practice

TABLE 1. Com parison of Delirium , Dem entia, and Depression

Delirium Dementia Depression Onset Sudden: Hours or days Gradual over months or years

‘ Gradual over weeks or months, or after an event

Alertness/ Attention

Fluctuates: Sleepy or agitated, unable to concentrate

Generally stable Generally stable, some difficulty concentrating

Sleep Sudden changes in sleeping pattern, unusual confusion at night

Can be disturbed, with habitual night-time wandering

Early morning waking

Thinking Disorganized, rambling Specific, difficulty with short-term memory

Preoccupied with negative thoughts, hopelessness, help­ lessness, self-depreciation

Perception Delusions, hallucinations common Generally normal Generally normal

Source: Holly et al., 2012

TABLE 2. Predisposing and Precipitating Factors fo r Delirium

Predisposing Factors Precipitating Factors

Age a 65 Use of sedative hypnotics, opioids, or Male sex anticholinergic drugs Co-existing dementia/cognitive Stroke

impairment Infections History of delirium Hypoxia Depression Shock Functional dependence Fever or hypothermia Immobility Anemia Low level of activity Poor nutritional status History of falls Recent surgery (major/minor) Visual impairment Admission to an intensive care unit Hearing impairment Use of physical restraints Dehydration Use of indwelling urinary catheter Malnutrition Multiple procedures Polypharmacy Pain Alcohol/drug abuse Emotional stress

Prolonged sleep deprivation

Source: Sendelbach & Guthrie, 2009

et al., 2014). Delirium is common among elders in long-term care (LTC) facilities, with its prevalence ranging from 9.6% to 89% (Voyer et al., 2008).

Although common, delirium often is under-recognized and under-diagnosed (O’Mahony et al., 2011). Because of the high incidence and costs associated with delirium, prevention should be a high priority for health care professionals, espe­ cially nurses (Harris, Chodosh, Vassar, Vickrey, & Shapiro, 2009).

Nurses spend more time with patients, allowing them to observe any changes in patients’ attention, level of consciousness, and cognitive function (Brixey & Mahon, 2010). As a result, frequent assessments by nurses are crucial for early detection of delirium (Girard et al., 2008).

Literature Review A comprehensive review of the

literature was conducted of all orig­ inal research published 2001-2014

using MEDLINE, CINAHL, and ProQuest Psychology Journals. Search terms included delirium or acute confusion and nurses, nurses’ recognition, nurses’ identification, or nurses’ knowledge. Exclusion criteria were studies not reporting primary data and studies that did not include measurement of nurse recognition or knowledge of deliri­ um. Although now dated, the selected research specifically evalu­ ated nurses’ knowledge deficit for delirium in studies of various designs. In addition, fewer studies actually assessed the levels of knowledge about delirium factors, such as definition, available and appropriate assessment scales/tools, and risks (Hare, Dianne, Sunita, Ian, & Gaye, 2008).

Many studies of delirium focused on the advantages of educated intervention, such as prevention practices, increased early detection, and proper medical management (Bergmann, Murphy, Kiely, Jones, & Marcantonio, 2005; Featherstone & Hopton, 2010; Rapp, Mentes, & Titler, 2001). Researchers also found a positive correlation between use of an educational intervention for nursing and medical professionals and positive patient outcomes such as decreased length of hospital stay (Meako, Thompson, & Cochrane, 2011; Tabet et al., 2005). Fick and co-authors (2007) found using case vignettes could evaluate nurses’

16 lanuary -F ebrua ry 2015 • Vol. 24 /N o. 1 MEDSURG N U R S IISTO

Delirium: Why Are Nurses Confused?

knowledge of delirium in patients with dementia.

Hare and colleagues (2008) tar­ geted 1,097 clinical nurses in a hos­ pital setting with a questionnaire to assess their knowledge of delirium and its associated risk factors. Of the 338 (30.8%) returned responses, 64% (n=217) scored 50% or better on the questionnaire. In addition, 36.3% (n=123) scored 50% or better for the risk factor questions while 81.9% («=227) scored 50% or better for the knowledge questions. Find­ ings indicated orthopedic nurses who had participated in a delirium education forum prior to the research scored better on the gener­ al facts portion of the questionnaire when compared to nurses having no pre-survey educational interven­ tion. However, the orthopedic nurs­ es did not score higher compared to other surveyed nurses on the risk factor questions. The researchers thus found nurses were not as knowledgeable about delirium risk factors as they were about general facts concerning delirium.

Fick and co-authors (2007) also assessed nurses’ knowledge of deliri­ um but more narrowly focused on delirium superimposed on dementia (DSD), with the goal of determining if nurses were able to recognize these conditions using case vignettes. The case vignettes were designed to eval­ uate knowledge of delirium, its risk factors, and management. The study also assessed nurses’ geropsychiatric knowledge using the Mary Starke Harper Aging Knowledge Exam (MSHAKE), a tool that measures gen­ eral geropsychiatric knowledge. Of 29 participating nurses, 41% (n=12) were able to identify dementia cor­ rectly in the dementia vignette but had difficulty differentiating deliri­ um factors from DSD factors and specifically identifying hypoactive delirium. While this study had a small sample size, its findings sug­ gested nurses are more likely to dis­ tinguish dementia and hyperactive delirium than DSD and hypoactive delirium alone.

Dahlke and Phinney (2008) eval­ uated how nurses assess, prevent, and treat delirium in older hospital­ ized patients, and identified deliri­

um-related challenges and barriers faced by nurses when caring for patients with delirium. This descrip­ tive qualitative study comprised interviews with nurses who worked in a hospital. A convenience sam­ pling included 12 registered nurses in a mid-sized regional hospital in western Canada who had manageri­ al, educational, and bedside roles and worked in various areas such as medical and surgical units. The nurs­ es in the study had 6-43 years of nursing experience. Level of profes­ sional education included diploma («=7), baccalaureate (n=4), and mas­ ter’s degree {n= 1). Each respondent was interviewed for approximately 1.5 hours with open-ended ques­ tions about his or her clinical and personal experience with delirium assessment, recognition, and inter­ vention. Analysis of the recorded interviews yielded three main deliri­ um-related strategies: Taking a Quick Look, Keeping an Eye on Them, and Controlling the Situation.

Taking a Quick Look suggested nurses quickly assess patients because of the limited time general­ ly available in a fast-paced acute care setting (Dahlke & Phinney, 2008). Keeping an Eye on Them rec­ ommended frequent rounding and monitoring of patients assessed to be at risk for delirium. Controlling the Situation focused on intervening as needed to prevent injury and provide appropriate therapy. Au­ thors found nurses repeatedly reported having little to no formal education about older adults and had sparse formal knowledge of delirium; they concluded nurses would benefit from increased deliri­ um-related educational support.

Additional research assessing nurses’ knowledge of delirium has been completed in LTC settings. Voyer and co-authors (2008) assessed nurse detection of delirium in older adults. This prospective study identified the signs and symptoms most challenging to dis­ tinguish, as well as delirium factors most likely to go unnoticed. At three LTC facilities and a large regional hospital LTC unit over two 7-day periods, trained research assistants (nurses who had complet­

ed 15 hours of instruction on delir­ ium and dementia detection) inter­ viewed 160 consenting patients age 65 and over with no history of psy­ chiatric illness. Investigators collect­ ed relevant demographic and health information and assessed patients for delirium as part of their interviews. Nurses were questioned about their ability and experience in assessing delirium in patients. The incidence of delirium among patient participants was 71.5% (n=108); of those, nurses identified delirium in just 13% (n=14). Authors concluded nurses under­ recognize delirium in older adults in the LTC setting.

Purpose Nurses’ failure to differentiate and

recognize delirium early may be due to lack of knowledge about delirium, risk factors, preventive measures, and treatment. Therefore, the pur­ pose of this study was to assess nurs­ es’ knowledge of delirium and its risk factors, and correlate findings to demographic variables, such as nurs­ es’ years of experience, level of edu­ cation, and area of practice. The study also was designed to evaluate nurses’ perception of their own level of competency related to delirium recognition and management.

Research Questions Research questions addressed in

this study included the following: 1. What was nurses’ level of

knowledge of delirium? 2. What was nurses’ level of know­

ledge of delirium risk factors? 3. Was there a correlation be­

tween nurses’ years of experi­ ence, education, and practice area, and their knowledge of delirium and its risk factors?

4. How did nurses perceive their own knowledge competency related to delirium?

Hypotheses 1. Nurses have insufficient knowl­

edge of delirium and its risk fac­ tor as evidenced by scoring less than 75% on the questionnaire.

2. A high correlation exists be­ tween a nurse’s level of experi­ ence, education, and area of

MEDSURG n uhs img. J a n u a ry -F e b ru a ry 2015 • Vol. 2 4 /N o . 1 17

Research for Practice

practice, and his or her knowl­ edge of delirium and its risk fac­ tors.

M e th o d s After receiving institutional re­

view board approval from the affili­ ated hospital and university in the Southeast region of the United States, researchers sent an an­ nouncement about the study by mass email to potential respondents who were nurses employed at this hospital. This nonexperimental, descriptive study was conducted over a 2-week period. Researchers manually distributed 150 question­ naires to every hospital unit (med­ ical-surgical, orthopedic, oncology, progressive care, neuro-intensive care, medical-surgical intensive care, cardiac care) to nurses who volunteered to participate in the study.

Instrum entation The research instrument used in

this study was used previously in a similar study (Hare et al., 2008). Permission to use the questionnaire was obtained from its original developers (M. Hare, personal com­ munication, March 15, 2011). The questionnaire, which was untitled in the previous study, was labeled for the current study as Nurses’ Knowledge of Delirium (NKD) (Hare et al., 2008). The NKD ques­ tionnaire has neither been validated nor had its reliability established (M. Hare, personal communication, September 22, 2011). However, the developer explained many other researchers and organizations world­ wide, such as National Health Service in the Great Britain, have utilized all or part of the question­ naires subsequent to the original study; thus, validation and reliabili­ ty may have been established with­ out the knowledge of the developers (M. Hare, personal communication, September 22, 2011).

The NKD questionnaire has two sections: a 10-question section for demographic data collection and 36 specific delirium-related questions called the knowledge section. The demographic section required par­

ticipants to provide age, sex, prac­ tice setting, specialty, level of educa­ tion, and years of nursing experi­ ence. Participants also were asked if they had experience in caring for a patient with delirium; if so, how fre­ quently had they provided care and had they received any formal deliri­ um-related continuing education? Respondents also were asked to pro­ vide their perceptions of their cur­ rent personal knowledge of deliri­ um by selecting one of the follow­ ing descriptors: lack competency, minimal competency, average compe­ tency, above average competency, advanced competency, or expert com­ petency. The demographic section required written responses and con­ tained multiple-choice questions except respondent age.

In the knowledge section of the questionnaire, participants identi­ fied the definition of delirium in a multiple-choice question, and seven scales/tools commonly used when assessing patients with delirium, dementia, and/or depression. All 28 remaining questions in this section assessed respondents’ general knowledge of delirium and its risk factors using a Likert-scale (agree, disagree, or unsure). This section contained one definition question, seven scales/tools questions, 14 general questions about delirium, and 14 questions about risk factors in a randomly mixed sequence. Participants independently com­ pleted just one of the forms in its entirety and placed finished ques­ tionnaires in a collection folder located in the nurses’ lounges on each unit. The tool did not request any identifying information from participants so anonymity was maintained.

Collection o f Data and Analysis o f Data

Once the questionnaires were collected, answers were compared to a codebook or key created to pro­ vide quick, accurate assignment of numerical values to the different answers for analysis. Completed questionnaires were crosschecked manually with the answer key and entered into an Excel spreadsheet to construct a database. Percentages

and means were used to describe the demographic variables. The completed database then was exported to SPSS version 15 (IBM, Chicago, IL) for detailed analysis. Researchers used analysis of vari­ ance (ANOVA) to determine if a cor­ relation existed between nurses’ demographic characteristics and their knowledge of delirium and delirium risk factors, and nurses’ perceptions of personal competen­ cy related to delirium. For the pur­ pose of this study, p<0.05 indicated statistical significance.

Find ings

Demographics Of the targeted 150 potential

nurse participants, 60 (40%) com­ pleted survey questionnaires; one questionnaire was excluded as com­ pleted by a non-nurse. Researchers categorized respondents by age: 19 respondents (31.67%) were ages 20- 30, 17 (28.33%) were ages 31-40, 10 (16.67%) were ages 41-50, and 14 (23.33%) were age 50 or older. Eighty-three percent of respondents were female.

Thirty-four respondents (56.67%) held a BSN degree, 18 (30%) held an ADN degree, six (10%) held an MSN degree with preparation as either a nurse practitioner or clinical nurse specialist, and two (3.33%) indicat­ ed they held a diploma in nursing.

Twenty respondents (33%) indi­ cated they had practiced as nurses 4-7 years, 14 (23.33%) had practiced 20 years or more, and nine (15%) less than 3 years. All respondents worked in an acute care setting; 35 (58.33%) practiced on a medical- surgical unit, 20 (33.33%) in a criti­ cal care unit, two (3.33%) in a surgi­ cal area, two (3.33%) in “other” areas (e.g., rehabilitation or primary care area), and one (1.67%) in a post-anesthesia care unit. Forty-two (75%) respondents reported having received no prior delirium-related education and 50 (83.33%) indicat­ ed they would be interested in receiving education about delirium. Finally, 51 respondents (85%) said they had provided care previously to patients with delirium.

January-February 2015 • Vol. 24/No. 1 MEDSURG NURSING-18

Delirium: Why Are Nurses Confused?

Knowledge and Risk Factors Scores

Of 36 questions on the NKD ques­ tionnaire, respondents answered an average of 23.10 (64.17%) correctly. Only 12 respondents (20%) scored 75% or greater on the question­ naire. Total knowledge and risk fac­ tor scores included only respon­ dents who correctly answered ques­ tions, not those who responded incorrectly or “unsure.”

Research Question 1: What is nurses’ level of knowledge of delirium? Twenty-two questions specifically required participants to answer gen­ eral knowledge questions about delirium. The average number of knowledge questions answered cor­ rectly was 15.32 (42.55%) (see Table 3). Twenty-one (35%) respondents scored 75% or greater on the deliri­ um questions.

Research Question 2: What is nurses’ level of knowledge of delirium risk factors? Fourteen questions required correct identification of delirium risk factors. The average number of risk factor questions answered correctly was 7.78 (21.62%). However, only six (10%) respondents scored greater than 75% on this group of questions (see Table 4).

Research Question 3: Is there a correlation between nurses’ years of experience, level of education, and prac­ tice area, and their knowledge of deliri­ um and its risk factors? No significant correlation was found between the level of education and the number of correct answers to general delirium questions (/;=().063) or risk factor questions (p=0.629). Researchers found no statistical significance in correlating the number of years of nursing practice and the number of correct answers in general delirium questions (p=0.217) and risk factor questions (/;=().809). Finally, no sig­ nificant correlation existed between the correct answer of delirium ques­ tions and risk factor questions and the specific areas of practice (p=0.823 and /;=0.560).

Research Question 4: How do nurses perceive their own competency of delirium? Just one (1.67%) partici­ pant self-described as having advanced competency. Nine (15%)

considered themselves to have above average competency about delirium, 33 (55%) perceived themselves of average competency, 11 (18.33%) reported minimal competency, and six (10%) said they lacked compe­ tence. Less than half the participants scored at least 75% on both the gen­ eral delirium and risk factor ques­ tions. No statistical significance was found between knowledge and nurs­ es’ level of education, experience, or area of practice. In addition, re­ searchers found no significant corre­ lations between knowledge (general and risk factors) and receipt of previ­ ous education about delirium (p=0.352 and p=0.270). However, this study incidentally determined a statistically significant difference in nurses who previously had cared for patients with delirium and the num­ ber of correctly answered general knowledge questions (p=0.028). However, there was no statistical sig­ nificance for the risk factor questions (p=0.212).

Nurses had a significant lack of knowledge about delirium and its risk factors. Only 12 of 60 respon­ dents (20%) scored at least 75% to be considered generally knowledge­ able. Further, the study found no correlation between education level, years of experience, or area of practice, and nurses’ general knowl­ edge of delirium and its risk factors. However, nurses with experience caring for patients with delirium scored higher in the general deliri­ um knowledge than those who lacked that experience. While more than half the respondents described themselves as having an average knowledge of delirium, exactly 80% (?z=48) failed to score 75% (having average competency).

Limitations The study tool was not validated

formally. However, the question­ naire’s authors explained all or part of the instrument had been used in other studies and programs, and may in fact, have been validated elsewhere. In addition, this study was conducted in only one hospital and, as a result, response rates were too low to achieve statistically sig­ nificant results.

Nursing Implications Because delirium may be difficult

to recognize, it subsequently is under-recognized and under-treated by health care professionals (O’Ma- hony et al., 2011; Rice et al., 2011). However, all nurses have the responsibility to identify risk factors and signs and symptoms of deliri­ um to lessen complications in acute and primary care settings (Rice et al., 2011). Completing routine assessments, recognizing predispos­ ing and precipitating risk factors, and using delirium scales for pre­ vention and treatment are key nurs­ ing responsibilities.

Assessing the knowledge of nurs­ es is a crucial step toward quantify­ ing any knowledge deficit before creating appropriate remedial edu­ cation programs. Hare and col­ leagues (2008) determined the nurs­ ing delirium risk factors knowledge deficit was lower (46.15%) than general knowledge (64.91%). This finding also was confirmed in this study where the average risk factor questions answered correctly was 7.78 (21.62%) and the average knowledge questions answered cor­ rectly was 15.32 (42.55%). The cur­ rent study findings differed from those of Hare and colleagues in that scores on both risk factor and gener­ al knowledge questions were lower than those reported by Hare. Nurses must continue to expand their knowledge of delirium in order to provide frequent and accurate assessments required to intervene before delirium further complicates patients’ health (Martinez, Tobar, Bedding, Vallejo, & Fuentes, 2012).

Conclusion Delirium is a common disorder. If

the condition is not treated properly or if preventive interventions are delayed, the patient may continue to deteriorate and become functionally impaired. This could lead to long­ term care placement and even death. In this study, a nursing knowledge deficit regarding general characteris­ tics of delirium and its risk factors was identified. Education of nurses in all care settings is vital for future

MEDSURG i s r u r iR B r j s r o , january-February 2015 • Vol. 24/No. 1 19

Research for Practice TABLE 3.

Questionnaire Results for Knowledge of Delirium

Question Correct Answer

n (%) Incorrect Answer

n (%) Unsure Answer

n (%) 2.1 Delirium: an acute confusion, fluctuating mental

state, disorganized thinking, altered level of consciousness.

51 (85.00%) 9 (15.00%) 0

2.2 Mini Mental State Examination (Delirium/Dementia)

9 (15.00%) 51 (85.00%) 0

2.3 Glasgow Coma Scale (None) 43 (71.67%) 17 (28.33%) 0

2.4 Delirium Rating Scale (Delirium) 51 (85.00%) 9 (15.00%) 0

2.5 Alcohol Withdrawal Scale (Delirium) 25 (41.67%) 35 (58.33%) 0

2.6 Confusion Assessment Method (Delirium) 16 (26.67%) 44 (73.33%) 0

2.7 Beck’s Depression Inventory (Depression) 50 (83.33%) 10 (16.67%) 0

2.8 Braden Scale (None) 52 (86.67%) 8 (13.33%) 0

2.9 Fluctuation between orientation and disorientation is not typical of delirium. (False)

43 (71.67%) 11 (18.33%) 6 (10.00%)

2.10 Symptoms of depression may mimic delirium. (True)

36 (60.00%) 17 (28.33%) 7 (11.67%)

2.11 Treatment for delirium always includes sedation. (False)

43 (71.67%) 6 (10.00%) 11 (18.33%)

2.12 Patients never remember episodes of delirium. (False)

43 (71.67%) 4 (6.67%) 13 (21.67%)

2.13 A Mini Mental Status Examination (MMSE) is the best way to diagnose delirium. (False)

28 (46.67%) 11 (18.33%) 21 (35.00%)

2.15 Delirium never lasts for more than a few hours. (False)

51 (85.00%) 4 (6.67%) 5 (8.33%)

2.28 A patient who is lethargic and difficult to rouse does not have a delirium. (False)

29 (48.33%) 16 (26.67%) 15 (25.00%)

2.29 Patients with delirium are always physically and/or verbally aggressive. (False)

52 (86.67%) 3 (5.00%) 5 (8.33%)

2.30 Delirium is generally caused by alcohol withdrawal. (False)

35 (58.33%) 18 (30.00%) 7 (11.67%)

2.31 Patients with delirium have a higher mortality rate. (True)

41 (68.33%) 7 (11.67%) 12 (20.00%)

2.33 Behavioral changes in the course of the day are typical of delirium. (True)

48 (80.00%) 6 (10.00%) 6 (10.00%)

2.34 A patient with delirium is likely to be easily distracted and/or have difficulty following a conversation. (True)

56 (93.33%) 2 (3.33%) 2 (3.33%)

2.35 Patients with delirium will often experience perceptual disturbances. (True)

59 (98.33%) 0 1 (1.67%)

2.36 Altered sleep/wake cycle may be a symptom of delirium. (True)

58 (96.67%) 0 2 (3.33%)

20 january-February 2015 • Vol. 24/No. 1 MEDSURG NURSING

Delirium: Why Are Nurses Confused?

TABLE 4. Results for Questions Relating to Risk Factors for Delirium

Question Correct Answer

n (%) Incorrect Answer

n (%) Unsure Answer

n(% ) 2.14 A patient having a repair of a fractured neck or

femur has the same risk for delirium as a patient having an elective hip replacement. (False)

12 (20.00%) 40 (66.67%) 8 (13.33%)

2.16 The risk for delirium increases with age. (True) 52 (86.67%) 5 (8.33%) 3 (5.00%)

2.17 A patient with impaired vision is at increased risk of delirium. (True)

36 (60.00%) 11 (18.33%) 13 (21.67%)

2.18 The greater the number of medications a patient is taking, the greater his or her risk of delirium. (True)

55 (91.67%) 2 (3.33%) 3 (5.00%)

2.19 A urinary catheter in situ reduces the risk of delirium. (False)

45 (75.00%) 8 (13.33%) 7 (11.67%)

2.20 Gender has no effect on the development of delirium. (False)

27 (45.00%) 15 (25.00%) 18 (30.00%)

2.21 Poor nutrition increases the risk of delirium. (True)

52 (86.67%) 2 (3.33%) 6 (10.00%)

2.22 Dementia is the greatest risk factor for delirium. (True)

16 (26.67%) 30 (50.00%) 14 (23.33%)

2.23 Males are more at risk for delirium than females. (True)

14 (23.33%) 13 (21.67%) 33 (55.00%)

2.24 Diabetes is a high risk factor for delirium. (False)

7 (11.67%) 34 (56.67%) 19 (31.67%)

2.25 Dehydration can be a risk factor for delirium. (True)

58 (96.67%) 0 (0.00%) 2 (3.33%)

2.26 Hearing impairment increases the risk of deliri­ um. (True)

37 (61.67%) 12 (20.00%) 11 (18.33%)

2.27 Obesity is a risk factor for delirium. (False) 38 (63.33%) 4 (6.67%) 18 (30.00%)

2.32 A family history of dementia predisposes a patient to delirium. (False)

18 (30.00%) 29 (48.33%) 13 (21.67%)

prevention and recognition of deliri­ um. Education should incorporate assessment and prevention strategies in caring for patients with delirium or those who have an increased risk for developing delirium. Education can provide nurses the foundation they need to become more proactive in addressing this under-recognized condition (Conley, 2011; Rice et al., 2011). EE3

REFERENCES American Psychiatric Association. (2011).

Diagnostic and statistical manual of mental disorders (4th ed., text rev). Washington, DC: Author.

Bergmann, M.A., Murphy, K.M., Kiely, D.K., Jones, R.N., & Marcantonio, E.R. (2005). A model for management of delirious

postacute care patients. Journal of the American Geriatrics Society, 53(10), 1817-1825.

Brixey, M.J., & Mahon, S.M. (2010). A self- assessment tool for oncology nurses: Preliminary implementation and evalua­ tion. Clinical Journal of Oncology Nursing, 14(4), 474-480. doi:10.1188/10. C JON.474-480

Conley, D. (2011). The gerontological clinical nurse specialist’s role in prevention, early recognition, and management of delirium in hospitalized older adults. Urologic Nursing, 31(6), 337-343.

Dahlke, S., & Phinney, A. (2008). Caring for hospitalized older adults at risk for deliri­ um: The silent, unspoken piece of nurs­ ing practice. Journal of Gerontological Nursing, 34(6), 41-47.

Featherstone, I., & Hopton, A. (2010). An inter­ vention to reduce delirium in care homes. Nursing Old People, 22(4), 16- 21.

Fick, D.M., Hodo, D.M., & Lawrence, F. (2007) . Recognizing delirium superim­ posed on dementia: Assessing nurses’ knowledge using case vignettes. Journal of Gerontological Nursing, 33(2), 40-47.

Girard, T.D., Panharipande, P.P., & Ely, E.W. (2008) . Delirium in the intensive care unit. Critical Care, 72(Suppl. 3). doi:10.1186/cc6149

Hare, M., Dianne, W., Sunita, M., Ian, L., & Gaye, S. (2008). A questionnaire to determine nurses’ knowledge of delirium and its risk factors. Contemporary Nurse, 29(1), 23-31.

Harris, D.P., Chodosh, J., Vassar, S.D., Vickrey, B.G., & Shapiro, M.F. (2009). Primary care providers’ views of chal­ lenges and rewards of dementia care rel­ ative to other conditions. The Journal of American Geriatrics Society, 57(12), 2209-2216. doi: 10.1111/j.1532-5415. 2009.02572.x

MEDSURG nursing. January-February 2015 • Vol. 24/No. 1 21

Research for Practice Holly, C., Cantwell, E.R., & Jadotte, Y. (2012).

Acute delirium: Differentiation and care. Critical Care Nursing Clinics o f North America, 24(1), 131-147.

Kalish, V., Gillham, J., & Unwin, B. (2014). American Family Physician, 90(3), 151- 158.

Lee, K.H., Ha, Y.C., Lee, Y.C., Kang, H., & Koo, K.H. (2011). Frequency, risk factors, and prognosis of prolonged delirium in elderly patients after hip fracture surgery. Clinical Orthopedic Relations Research, 469(9), 2612-2620.

Martinez, F.T., Tobar, C., Bedding, C.I., Vallejo, G., & Fuentes, P. (2012). Preventing delir­ ium in an acute hospital using a non-phar- macological intervention. Age Aging, 41(5), 629-634.

Meako, M.E., Thompson, H.J., & Cochrane, B.B. (2011). Orthopaedic nurses’ knowl­ edge of delirium in older hospitalized patients. Orthopaedic Nursing, 30(4), 241 -248. doi:10.1097/NOR.Ob013e318 2247c2b

O’Mahony, R., Murthy, L., Akunne, A., & Young, J. (2011). Synopsis of the National Institute for Health and clinical excellence guideline for prevention of delirium. American College o f Physicians, 754(11), 746-751.

Quinlan, N., Marcantonio, E.R., Inouye, S.K., Gill, T.M., Kamholz, B., & Rudolph, J.L. (2011). Vulnerability: The crossroads of frailty and delirium. Journal o f American Geriatric Society, 59(Suppl. 2), S262- S268.

Rapp, C.G., Mentes, J.C., & Titler, M.G. (2001). Acute confusion/delirium protocol. Journal of Gerontological Nursing, 27(4), 21-33.

Rice, K., Bennett, M., Gomez, M., Theall, K., Knight, M., & Foreman, M. (2011). Nurses’ recognition of delirium in the hos­ pitalized older adult. Clinical Nurse Specialist, 25(6), 299-311.

Sendelbach, S., & Guthrie, P.F. (2009). Evidence-based guideline: Acute confu­ sion/delirium identification, assessment, treatment, and prevention. Journal of Gerontological Nursing, 35(11), 11-18.

Siddiqi, N., Young, J., & Cheater, F. (2008). Educating staff working in long-term care about delirium: The Trojan horse for improving quality of care. Journal o f Psychosomatic Research, 65(3), 261- 266.

Tabet, N., Hudson, S., Sweeney, V., Sauer, J., Bryant, C., MacDonald, A., & Howard, R. (2005). An educational intervention can prevent delirium on acute medical wards. Age and Ageing, 34(2), 152-156. doi:10.1093/ageing/afi031

Voyer, R, Richard, S., Doucet, L., Danjou, C., & Carmichael, PH. (2008). Detection of delirium by nurses among long-term care residents with dementia. BMC Nursing, 7(4), 1-14. doi:10.1186/1472-6955-7-4

Wofford, K., & Vacchiano, C. (2011). Sorting through the confusion: Adverse cognitive change after surgery in adults. AANA Journal, 79(4), 335-342.

Young, J., & Inouye, S. (2007). Delirium in older people. British Medical Journal, 334 (7598), 842-846.

Bathing Persons with Dementia

AMSN President’s Message continued from page 5

continued from page 14

Rasin, J., & Barrick, A.L. (2004). Bathing patients with dementia. American Journal o f Nursing, 104(3), 30-33.

Rozzini, R., Sabatini, T., Ranhoff, A.H., & Trabucchi, M. (2007). Bathing disability in older persons. JAGS, 55, 635-636.

Sangeeta, C., Ahluwalia, S.C., Gill, T.M., Baker, D.I., & Fried, T.R. (2010). Perspectives of older persons on bathing and bathing disability: A qualitative study. JAGS, 58, 450-456.

Shelkey, M., & Wallace, M. (2012). Katz index o f independence in activities o f daily liv­ ing (ADL): Best practices in nursing care to older adults. New York, NY: Hartford Institute for Geriatric Nursing.

Sidani, S., LeClerc, C., & Streiner, D. (2009). Implementation of the abilities-focused approach to morning care of people with dementia by nursing staff. International Journal o f Older People Nursing, 4(1), 48-56. do i: 10.1111 /j. 1748-3743.2008. 00154.x

Smith, A.K., Walter, L.C., Miao, Y., Boscardin, W.J., & Covinsky, K.E. (2013). Disability during the last two years of life. JAMA Internal Medicine, 173, 1506-1513.

Theou, O., Rockwood, M.R., Mitnitski, A., & Rockwood, K. (2012). Disability and co­ morbidity in relation to frailty: How much do they overlap? Archives of Gerontology and Geriatrics, 55(2), e1-8.

Touhy, T.A., & Jett, K.F. (2014). Ebersole & Hess’ gerontological nursing & healthy aging (4th ed.). St. Louis, MO: Elsevier Mosby.

Zingmark, M., & Bernspang, B. (2011). Meeting the needs of elderly with bathing disability. Australian Occupational Thera­ py Journal, 58(3), 164-171. doi:10.1111/j. 1440-1630.2010.00904.x

All Nurses Are Leaders Developing leadership skills is challenging as well as rewarding.

Throughout my career, I have had mentors who have provided guidance. 1 believe it is our responsibility as nurse leaders to share our wisdom with our colleagues. Take the time to seek a mentor and discuss your career plans. That person will have a wealth of knowledge to share and may spark an interest in a path you have not considered previously. If you are currently a seasoned nurse, seek mentoring opportunities. Taking an active part in developing nurses for future leadership roles has been a personally reward­ ing component of my career.

1 challenge you to find opportunities to continue to develop your leader­ ship skills. The AMSN Clinical Leadership Development Program is a course I strongly encourage you to complete. Maybe this is the right time in your life to participate in a hospital council as a member or chair. Answering a call to volunteer for AMSN may be in your future for 2015. Seek new experi­ ences. Rely on mentors for advice and guidance. Become an active partici­ pant in the redesign of health care. Wherever you are in your career path, remember, all nurses are leaders. L’.Hd

REFERENCE Institute of Medicine (IOM). (2011). The future o f nursing: Leading change, advancing health.

Washington, DC: National Academies Press.

Call for ‘Clinical How-To’ Submissions Are you a clinical expert? Share that expertise through the

“Clinical How-To” column in MEDSURG Nursing. Desired topics for this column in the coming year include tracheostomy care, care of the patient with a chest tube, IV access devices, total hip protocol to avoid dislocation (posterior approach), and neurovascular assessment. Please contact journal Editor Dottie Roberts (drobertscns@gmail.com) to dis­ cuss your interest and a possible timeline for submission.

22 january-February 2015 • Vol. 24/No. 1 MEDSURG N U R S I N G

Copyright of MEDSURG Nursing is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.