Delirium is a very serious disturbance caused in the mental abilities of an individual, which gives rise to confused thinking along with a reduction in the awareness of what is going around in the environment (Wilson et al., 2020). The case study is about Mr Thomas, who is a 69-year-old man of indigenous nature who was admitted to Royal Perth Hospital due to respiratory illness. He was seen with an alteration of mental state when he was advised to be admitted. Mr Thomas was suspected of having acquired pneumonia as his oxygen saturation levels were low. Moreover, he also was affected with partial blindness and diabetes mellitus. He was detected as having developed Delirium due to the underlying medical conditions.
Delirium is caused by a blend of risk and causative factors. With more risk factors, the vulnerability of the brain to precipitate delirium increases. A brain can experience Delirium in the same manner as a person has a seizure (Thom et al., 2019). Dementia is a predominant risk factor of Delirium. Other issues such as depression can also give rise to the same. The predisposing factors of Mr Thomas’ Delirium are visual impairment, increasing age and chronic medical conditions like diabetes mellitus and its medication, medicines such as Paracetamol. Among causative factors causing Delirium is a chest infection, which made him admitted to the hospital, and other infections.
Symptoms of Delirium include agitation and often hallucinations (Grover & Ghosh, 2018). Some of the symptoms of Mr Thomas which indicated Delirium were stopping to talk suddenly, acute cough and pneumonia and fluctuations. Moreover, the patient had acquired onset of an altered conscious state, and he was not being able to sleep properly and hence an altered sleep cycle. He was sleeping during the day and remaining awake at night. The speech of Mr Thomas had become slow and incoherent.
“The Diagnostic and Statistical Manual of Mental Disorders” specifies standard reference for delirium diagnosis as impairment of the cognitive process (Morandi et al., 2017). To diagnose the presence of Delirium in Mr Thomas, screening tools were used which could detect the changes in cognitive function. The Abbreviated Mental Test (AMTS) or the Mini-Mental State Examination (MMSE) was used for this purpose of diagnosis. In the MMSE, a score of 24 out of 30 will indicate impairment of cognitive functions. On the other hand, AMTS is a shorter 10-item screen which cognitive impairment. Here, a score of 7 is the threshold level. The cornerstone of diagnosing Delirium was to assess the baseline of the mental status with the detection of any changes (Oh et al., 2017). It was diagnosed from the tests that Mr Thomas was suffering from a mixed delirium, though it was initially thought that he was suffering from hypoactive Delirium as he was showing withdrawal symptoms along with apathy. Nighttime agitation was a feature of hyperactive Delirium. Hence, it has been concluded that Mr Thomas is suffering from mixed Delirium.
The evidence about how and when the assessment of Delirium is carried out in the nursing setting is inconsistent (Lamond, Murray & Gibson, 2018). The physical assessment of Mr Thomas was subjected to limited neurological examination. He had a height of 168 cm and weighed 75 kgs. His pupils were equal, and it was reactive to illumination. There was no asymmetry in the face noted. Sounds of breathing in the patient were less, along with bibasal and expiratory crackles along with scattered wheeze. There was the visibility of dual sounds of the heart, and no bruits were found. Pulses were normal, and no oedema was noted. Mr Thomas had a blood pressure of 100/60 mmHg, and this was taken when he was lying down. His pulse was detected to be 100 bpm. His abdomen was benign, and there were no sounds of bowel spotted. Sensation in all four limbs was very much normal.
The specificity of recognition of the feature of Delirium is substantially among patients with dementia. On clinical assessment, it was found that Mr. had an elevated CRP level of 96 mg/L. The level of sodium and potassium was elevated (152 mmol/L) and normal (4.6 mmol/L), respectively. It was found that the patient was suffering from dehydration along with substantial dysfunction of the renal system. The level of blood glucose was elevated (14.5 mmol/L), which was obvious in all people’s confusion. From the culturing of blood, it was confirmed that Mr Thomas was suffering from septicemia, which was related to pneumonia. There was no evidence of any kind of ischemic alterations as detected from the ECG. However, Sinus Tachycardia was detected in the same. The count of Haemoglobin, white blood cells and platelets were high, which is a possible cause of Delirium.
Preventing Delirium is of utmost importance as the number of evidence-based pharmacological treatments is very limited (Hayhurst, Pandharipande & Hughes, 2016). Taking care of a patient suffering from Delirium is not very easy as a number of factors have to be considered. The treatment and care process for Mr Thomas should involve the family with support from AHW. This should be done to make them engaged and encouraged to implement the interventions of care. The wife of Mr Thomas was encouraged to stay with him in the ward, especially at night. All the staff taking care were given stimuli that were meaningful.
There is a requirement of several multi-disciplinary interventions along with the collaboration of all healthcare staff to reduce and manage Delirium among patients (Igwe et al., 2020). The multi-disciplinary team at the hospital undertook a range of observations and measures of surveillance that included frequent observations of nursing along with prevention strategies. Mr Thomas was placed on physical therapy so that he could induce movability as the present illness has not given him scope to maintain normal activity. There was speech and language therapy along with dietetic therapy. The diet he was following was appropriate for diabetes, and the new treatment plan was set up so that he gets all nutrients in the form of a balanced diet, his bowel movements improve, and he becomes healthy. The medical team, along with the support of nursing staff, would restore physiological homeostasis while trying to detect any complications arising due to infection. Psychiatry, however, is not required for Mr Thomas.
The treatment program for Mr Thomas has the following goals:
The family of patients suffering from Delirium must work collaboratively with the nurses and doctors to bring down the duration of Delirium in patients (Smithburger et al., 2017). While dealing with the family of Mr Thomas, care has to be taken that the family has completely understood what has happened to the patient. Their concerns and questions have to be answered by the multi-disciplinary team, along with the provision of additional education whenever necessary. It is important to render follow-up care to the family such as transport, lodging, food, medicines so that they do not feel uncomfortable in the hospital setting.
Conclusion
It can be concluded that a patient diagnosed with Delirium is at high-risk and requires special attention. Thus, proper care has to be taken. Not only the patient but also the family must be catered to properly. Since Mr Thomas is of Aboriginal culture, he and his family have to be supported well so that they can overcome their cultural barriers easily.
Reference List
Grover, S., & Ghosh, A. (2018). Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 8(4), 460-470. https://dx.doi.org/10.1016%2Fj.jceh.2018.04.012
Hayhurst, C. J., Pandharipande, P. P., & Hughes, C. G. (2016). Intensive care unit delirium: a review of diagnosis, prevention, and treatment. Anesthesiology, 125(6), 1229-1241. https://pubs.asahq.org/anesthesiology/article-pdf/125/6/1229/487766/20161200_0-00033.pdf
Igwe, E. O., Nealon, J., Mohammed, M., Hickey, B., Chou, K. R., Chen, K. H., & Traynor, V. (2020). Multi-disciplinary and pharmacological interventions to reduce post-operative Delirium in elderly patients: a systematic review and meta-analysis. Journal of Clinical Anesthesia, 67, 110004. https://ro.uow.edu.au/smhpapers1/1516
Lamond, E., Murray, S., & Gibson, C. E. (2018). Delirium screening in intensive care: A life saving opportunity. Intensive and Critical Care Nursing, 44, 105-109. https://doi.org/10.1016/j.iccn.2017.04.014
Morandi, A., Davis, D., Bellelli, G., Arora, R. C., Caplan, G. A., Kamholz, B., Kolanowski, A., Fick, D. M., Kreisel, S., MacLullich, A., Meagher, D., Neufeld, K., Pandharipande, P. P., Richardson, S., Slooter, A. J., Taylor, J. P., Thomas, C., Tieges, Z., Teodorczuk, A., Voyer, P., … Rudolph, J. L. (2017). The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge. Journal of the American Medical Directors Association, 18(1), 12–18. https://doi.org/10.1016/j.jamda.2016.07.014
Mossello, E., Tesi, F., Di Santo, S. G., Mazzone, A., Torrini, M., Cherubini, A., … & Italian Study Group on Delirium. (2018). Recognition of delirium features in clinical practice: data from the “Delirium Day 2015” National Survey. Journal of the American Geriatrics Society, 66(2), 302-308. DOI:10.1111/jgs.15211
Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA, 318(12), 1161–1174. https://doi.org/10.1001/jama.2017.12067
Smithburger, P. L., Korenoski, A. S., Kane-Gill, S. L., & Alexander, S. A. (2017). Perceptions of family members, nurses, and physicians on involving patients’ families in delirium prevention. Critical Care Nurse, 37(6), 48-57. https://doi.org/10.4037/ccn2017901
Thom, R. P., Levy-Carrick, N. C., Bui, M., & Silbersweig, D. (2019). Delirium. American Journal of Psychiatry, 176(10), 785-793. https://doi.org/10.1176/appi.ajp.2018.18070893
Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M., … & Ely, E. (2020). Delirium. Nature Reviews Disease Primers, 6(1), 1-26. https://doi.org/10.1038/s41572-020-00223-4
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