Delirium Assessment and Management Presented by: Jonna Bobeck BSN, RN, CEN

IntroductionAcute change in consciousnessHyperactive deliriumHypoactive deliriumAssociated with increased length

of stayOften goes undetected

Supporting EvidenceNeed for standardized assessment toolsTools

◦Confusion Assessment Method (CAM-ICU)◦ Intensive Care Delirium Screening Checklist

(ICDSC)Also implementing the ABCDE bundle

◦A - awakening◦B - breathing◦C- coordination◦C- choice◦D - delirium

Supporting EvidenceUnderstudied and underreportedPre-existing dementia,

hypertension, alcoholism, and severity of illness

Recent studies conclude early mobility improves cognitive function

Decrease sedative use and modify iatrogenic risk factors

Managing ICU DeliriumThe FDA has not approved a drug

to treat deliriumFDA has issued an alert regarding

antipsychotic medicationAll patients receiving

antipsychotic medications should be closely monitored

Managing ICU DeliriumUse the THINK mnemonic

◦T- toxic situations◦H – hypoxemia◦I – infection/sepsis◦I – immobilization◦K – electrolyte abnormalities

Delirium ScreeningPatients admitted to Intermediate

or Advanced ICU with be screened for delirium on admission and at least every 12 hours thereafter

Process for UtilizationAdd the Delirium Screening to

interventionsComplete the screeningImplement the ABCDE bundle

Process for Utilization: Patient Positive for DeliriumOrientationEnvironmentClinical paramaters

Process for Utilization: Patient Positive for DeliriumPharmacologic

◦Use THINK mnemonic◦T – toxic situations◦H – hypoxemia◦I – infection/sepsis◦N – non-phamrocologic interventions◦K – postassium or electrolyte

problem

Early MobilizationPatients will be progressively

ambulated and mobilizedObjective assessment every 12

hours

Process for Utilization Step 1: baseline mobility

◦Passive ROM twice a day◦Turn every 2 hours◦Increase sensory stimulation during

day◦Allow rest at night◦Involve families

Process for UtilizationAssess mobility progression

criteria◦Responds to verbal stimuli with eye

opening◦Oxygen demands are stable◦No unstable fractures◦No increased titration of

vasopressors for 12 hours

Process for Utilization: Progressive MobilizationStep 2: bed to chair positionStep 3: life to chairStep 4: dangle on edge of bedStep 5: transfer to chairStep 6: standing at bedsideStep 7: ambulate at bedside

Process for UtilizationAssess tolerance of activity by:

◦Unexpected change in vs◦Symptomatic decrease in SBP◦Decrease in Scvo2◦Increase in FiO2◦Desaturation less than 90%◦Ventilator dysyncrony◦Sustained increase in secretions

Key PointsO2 may not be increased during

mobilizationNotify provider if FiO2 does not

return to baselineRT may adjust ventilator to

support increased requirementsAdvance only 1 step per day

Summary: Putting it all TogetherABCDE bundle

ReferencesPullman Regional Hospital,(2012).

Delirium screening protocol Retrieved from \\prhs5\groups\Policies and Procedures\Patient Care

Pullman Regional Hospital, (2012). Early mobilization of ventilator patients protocol Retrieved from \\prhs5\groups\Policies and Procedures\Patient Care