Long-Term Care Survey Alert

When it comes to delirium, one of the best clinical and survey tools you can produce is a well-written care protocol to assess, report and treat this often life-threatening condition.

And make it detailed so all members of the nursing and interdisciplinary team know exactly what to do, advises Barbara Miltenberger, a nurse attorney in Jefferson City, MO.

For example, Miltenberger suggests a nursing directive could say: "If the patient is losing concentration or becoming disoriented, check his temperature, lung sounds and do a urinalysis." That way staff could detect pneumonia or a urinary tract infection two common causes of delirium in elderly residents.

"The protocol should also direct staff to check the delirious resident for a broken bone, such as a spontaneous fracture, pain and dehydration," Miltenberger advises. Mines suggests nurses check the patients latest electrolytes or ask the physician to order a panel.

As part of standard procedure, the consulting pharmacist should evaluate whether a drug or drug toxicity could be causing a residents delirium.

Drug-induced delirium is commonly caused in nursing home settings by pain medication, anticholin-ergic drugs and cardiac drugs, according to Laura Gervasi, a psychiatric nurse who spoke at the recent National Association of Directors of Nursing Administration in Long-Term Care conference.

One of the best ways to prevent delirium is to address the acute medical problems known to trigger the condition. For example, Smithfield Manor in Smithfield, NC does care plans on residents at risk for delirium due to conditions such as congestive heart failure, acute infection, diabetes or fluid and electrolyte disturbances, reports Sandra Parrish, the facilitys resident assessment nurse.

The care plan includes interventions to address the medical problem, as well as directives for assessing and reporting delirium to the physician.

Residents who develop delirium require standard nursing interventions to promote safety and recovery and ease their agitation and fear. Gervasi suggests the following interventions, which should be individualized to each resident:

Monitor vital signs and intake and output.

Place the resident in the room right next to the nurses station and provide adequate supervision to maintain the residents safety.

Reorient the resident to date and environment (use calendars, clocks and familiar objects).

Ask a calm family member to stay with the resident during the episode.

Increase lighting in the room at bedtime to help eliminate illusions.

Ask the physician order medication to calm the delirious resident, but avoid anticholinergic drugs (such as Benadryl) that can worse the delirium.

Educate the resident/family about delirium to reduce their fear and embarrassment.

Nursing staff should also evaluate and document the residents response to any new physician orders designed to treat the underlying medical condition, such as oxygen, IV fluids or medications to relieve fever, infection or pain.