Nursing Case Study: Delirium, Pain Management and Strength-Based Approach

This nursing case study discusses the diagnosis, assessment tools, nursing interventions, and strength-based approach for patients with delirium and pain. It also highlights the importance of adhering to the Nursing and Midwifery Board of Australia standards for managing patients.

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NURSING CASE STUDY
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Introduction
The incidence of delirium is significantly higher in the older adults characterized with
impaired cognitive abilities and lack of awareness about the environment (Lawlor & Bush,
2014). The condition is diagnosed by a cognitive assessment to monitor and evaluate the
cognitive capacity of the affected individual that directs the treatment process and helps to
develop intervention strategies for the patient by accessing the physical and mental needs of the
patient (Lawlor & Bush, 2014). Health care professions especially the nurses working in such
settings are responsible for conducting necessary assessments required to access and understand
the patient’s condition more comprehensively and accurately that would help to plan and
implement the intervention strategies appropriate for the patient. The paper focuses on an
incident experienced by the protagonist of the video, Max, who is a delirium patient and
discusses on the nursing interventions by aligning with the Nursing and Midwifery Board of
Australia standards for managing the patients of delirium like Max.
Question 1:
Delirium is a serious and acute neuropsychiatric disorder characterized with cognitive
dysfunction and the etiology of the condition implicates the pathophysiological significances of
acute medical illnesses and complications or drug intoxication. The condition is diagnosed by a
cognitive assessment to monitor and evaluate the cognitive capacity of the affected individual
that directs the treatment process and helps to develop intervention strategies for the patient by
accessing both the physical and mental needs of the patient.

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Depending on the etiology and clinical severity, delirium can be of three types that
includes hyperactive, hypoactive and a mixed level of activity. It is evident from the studies that
hypoactive delirium is associated with severe complications and have resulted into a higher rate
of mortality among the individuals because of the difficulty in its diagnosis. Patients with
hyperactive delirium are disorientated, agitated and delusional and experience hallucinations.
Hypoactive delirium patients are subdued, disoriented and confused. However, the study by
Evensen et al., 2019, suggests that older people with delirium demonstrates a reduced activity
and there are no significant differences found between the three types of delirium, probably due
to poor gait function (Evensen et al., 2019).
According to the Diagnostic criteria of delirium IV, delirium is diagnosed by monitoring the
following criteria:
 Disturbances in consciousness, awareness and attention.
 Impaired cognition
 Inability to understand and interpret information stated by others.
 Collecting and accessing the patient’s history and through physical assessments that helps
to find the gather subjective and objective data of the patients and help to plan or develop
the intervention and treatment strategies.
 Other associated psychological issues identified in this area sleep disturbances, delusions,
inappropriate behaviour, emotional liability and perceptual disruptions. Delirium patients
are likely to suffer from a combinations of the above conditions needs serious treatment
and assistance both medical and psychological.

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Assessment tools used to diagnose delirium: The assessment tools for diagnosing delirium
includes:
 Confusion Assessment Method (CAM): CAM is used as a diagnostic tool for delirium
especially in the older patients. It provides a standardized method to detect delirium in
the patients.
 Confusion Assessment Method- Intensive Care Unit (CAM-ICU): This is a delirium
assessment tool used in the intensive care unit comprising of standardized nonverbal
assessments for the ICU patients.
 Delirium Symptoms Interview: It provides protocols to access the symptoms of the
patients delineated by the DSM-III criteria. This is mainly used with a combination of
other data obtained from the diagnostic criteria of delirium.
 Delirium Rating Scale: This is used by the researchers to accurately monitor the patient’s
cognitive capacity by addressing the signs and symptoms (Health.gov.au, 2019).
Studies have shown the importance and effectiveness of non-pharmacological therapies
beside medications or medical interventions for the treatment of patients suffering from delirium.
Nurses taking care of these patient must communicate with the patient effectively in
order to understand the patient’s condition more comprehensively and carry out effective
strategies to enable delivery of an enhanced and quality nursing care.
According to the Nursing and Midwifery Board of Australia standards, nurses must think
critically and analyse the situation and use the best available evidences to develop a quality care
plan for the patients that will improve the patient’s health outcome and eventually increase

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satisfaction of the patients (Nursingmidwiferyboard.gov.au, 2019). To care for the patient, Max,
the nurse must work thinking critically about the patient’s condition and practice by adhering to
the nursing codes of standard. According to the NMBA standards, the nurse must engage the
patient in therapeutic communication and professional relationship with the patient in order to
create an environment that of mutual trust (Nursingmidwiferyboard.gov.au, 2019). Nurses taking
care of these patients must engage them in professional relationship and therapeutic
communication (Nursingmidwiferyboard.gov.au, 2019). Nurses must respond to the patient on
priority basis and in a timely manner. Nurses must conduct assessment comprehensively and
carry out a holistic approach to care (Nursingmidwiferyboard.gov.au, 2019). Nurses while
working in clinical settings must possess the core competencies and skill set required to
appropriately understand the patient’s health condition more comprehensively and accurately
(Nursingmidwiferyboard.gov.au, 2019). They must collect every information and factors that
affect the health of the patients and develop intervention strategies based on them by reflecting
on their experience, knowledge and expertise towards achieving an improved health outcome. It
is the primary responsibility of the nurses to educate the patents on their health condition and
deliver them with every necessary information related to their health and the treatment options or
approaches available for the nurses must ensure a safe and high quality practice to facilitate an
enhanced nursing care that will improve the patient’s health outcome and increase patient’s
satisfaction.
As per the video, Max was not provided with sufficient information of his health and the
nurse did not take care of him by accessing his physical and mental needs. He was also not given
proper treatment and his pain was also not managed properly by the nurses that directed him to
consume marijuana.

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Question 2:
Pain acts as a risk factor for delirium. Evidences have suggested that pain and delirium
are found to patients during their stay at hospital, and therefore, pain and delirium assessments
are required for managing both of these conditions in the older patients (Feast et al., 2018). The
study by Feast et al., 2018 have suggested that old age, dementia, disabilities and other
comorbidities acts as predisposing factors. Other influencing factors like male sex, mild
cognitive impairment, poor vision and hearing and alcohol abuse acts associated with an
increasing risk.
Pain assessment in the older patients who are having cognitive impairment is difficult
since they are incapable of self-reporting their pain that has a negative impact on the
management of pain. Pain assessment therefore, is a crucial and fundamental step for screening
patients by using a validated assessment tool that helps in monitoring and evaluating the severity
of the pain by aligning the pain score with guidelines like, World Health Organization analgesic
ladder that helps to determine and plan a suitable intervention for managing pain of the patient
(Jones, Sim & Hughes, 2017). One of the assessment tools commonly used for pain management
in older patients having cognitive dysfunction is the Pain Assessment In Advanced Dementia
(PAINAD) scale. Using the scale properly can help decrease the risk of occurrence of pain in
patients suffering from cognitive impairment (Paulson, Monroe & Mion, 2014).
Poor pain management have negative impact on the patient. Untreated pain can have
immediate consequences on both psychological and physical health of the patients.
Max uses Marijuana to manage his pain. However, drug dependency can increase the
chance of developing is psychiatric comorbidities with significant changes in psychopathology,

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predominantly anxiety disorders and affective disorders, like depression. Such comorbidities can
also further complicate patients' behaviour and their interaction with nurses in the hospital
(Quinlan & Cox, 2017).
Question 3:
In the case scenario, Max exhibited concerns regarding his health issues such a
depression and osteoarthritis and medication management. In this case, the community nurse
must incorporate the principles of the strength-based approach in order to address the concern of
the patient and empower him. Mikkonen, Kyngäs and Kääriäinen (2015), highlighted that a
strength-based approach that holds the core belief that all individuals are unique and
have strengths and resources to overcome the difficulties they are experiencing in their life. The
practice mainly emphasises on a person's skills, interests and support systems. There are six
principles of strength-based approaches such as Focus on strengths, abilities, and potentials of
the patient, recognize the expertise of the participants, actively involved in the decision making
of the participants, focused on the social context and holistic care, use strength-based language
and encourage experiences. Recognize complexity and have commitments for social justice
(Cashin et al., 2016). In this current context, the community nurse effectively engages Max in the
communication and encourage him to share his experience of living with depression,
osteoarthritis, and depression and empathize him for feeling better. The community nurse
recognized that he is a unique individual and through the description of his experience,
community nurse identified the strength and weakness of him by incorporating the social context
of the patient. Consequently, the community nurse would be able to involve max in shared
decision making and assist him in self-management of depression, osteoarthritis, and medication

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management Cashin et al., 2016). Through the strength-based practice, the nurse would be able
to encourage Max to involve in the nursing intervention for medication management, depression,
and osteoarthritis.
This strength-based approach of community nurse would be effective for Max since
through effective therapeutic communication Max was able to recognize the strength and
eliminate the weakness of him (Tse et al., 2016). This strength-based approach provided the
nurse with an opportunity to support Max in taking problem-solving and recovery orientated
approach. He would be able to do self-management of adhering to the medication, reduction of
depression and osteoarthritis which will further empower him (Tse et al., 2016). The nurse can
involve his wife in this assessment for creating a safe and comfortable environment for Sam.
This initiative not only supports Max in involving in the shared decision making but gather a
perspective of living a healthy and purposeful life (Cashin et al., 2016).
Conclusion
Nurses must be compassionate and empathetic while taking care of these patients. Nurses
need to practice a holistic approach to care by providing the patient a therapeutic environment
and informing and educating the patient and the family members regarding the patient’s
condition, which was missing in case of Max. It is the primary responsibility of the nurses to
educate the patients on their health condition and provide them with every necessary information
related to their health and the treatment options or approaches available which was also breached
by the nurse taking care of Max. The nurse did not practice by adhering to the practice standards
as per the Nursing and Midwifery Board of Australia that eventually resulted into a poor health
outcome and decreased satisfaction of the patients.

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References:
Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., ... & Fisher, M. (2017).
Standards for practice for registered nurses in Australia. Collegian, 24(3), 255-266. Doi:
10.1016/j.colegn.2016.03.002
Evensen, S., Bourke, A. K., Lydersen, S., Sletvold, O., Saltvedt, I., Wyller, T. B., & Taraldsen,
K. (2019). Motor activity across delirium motor subtypes in geriatric patients assessed
using body-worn sensors: a Norwegian cross-sectional study. BMJ open, 9(2), e026401.
Doi: 10.1136/bmjopen-2018-026401
Feast, A. R., White, N., Lord, K., Kupeli, N., Vickerstaff, V., & Sampson, E. L. (2018). Pain and
delirium in people with dementia in the acute general hospital setting. Age and ageing,
47(6), 841-846. Doi: 10.1093/ageing/afy112
Health.gov.au. (2019). Department of Health | Delirium Diagnostic Tools. Retrieved 18
September 2019, from
https://www1.health.gov.au/internet/publications/publishing.nsf/Content/delirium-care-
pathways-toc~delirium-care-pathways-ddt
Jones, J., Sim, T., & Hughes, J. (2017). Pain Assessment of elderly patients with cognitive
impairment in the emergency department: Implications for pain management—A
narrative review of current practices. Pharmacy, 5(2), 30. Doi: 10.1093/ageing/afy112
Lawlor, P. G., & Bush, S. H. (2014). Delirium diagnosis, screening and management. Current
opinion in supportive and palliative care, 8(3), 286. Doi:
10.1097/SPC.0000000000000062

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Mikkonen, K., Kyngäs, H., & Kääriäinen, M. (2015). Nursing students’ experiences of the
empathy of their teachers: a qualitative study. Advances in Health Sciences Education,
20(3), 669-682. Doi: 10.1007/s10459-014-9554-0
Nursingmidwiferyboard.gov.au. (2019). Nursing and Midwifery Board of Australia - Registered
nurse standards for practice. Retrieved 19 September 2019, from
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards/registered-nurse-standards-for-practice.aspx
O'Sullivan, R., Inouye, S. K., & Meagher, D. (2014). Delirium and depression: inter-relationship
and clinical overlap in elderly people. The Lancet Psychiatry, 1(4), 303-311. Doi:
10.1016/S2215-0366(14)70281-0
Paulson, C. M., Monroe, T., & Mion, L. C. (2014). Pain assessment in hospitalized older adults
with dementia and delirium. Journal of gerontological nursing, 40(6), 10-15. Doi:
10.3928/00989134-20140428-02
Quinlan, J., & Cox, F. (2017). Acute pain management in patients with drug dependence
syndrome. Pain reports, 2(4). Doi: 10.1097/PR9.0000000000000611
Tse, S., Tsoi, E. W., Hamilton, B., O’Hagan, M., Shepherd, G., Slade, M., ... & Petrakis, M.
(2016). Uses of strength-based interventions for people with serious mental illness: A
critical review. International Journal of Social Psychiatry, 62(3), 281-291. Doi:
10.1177/0020764015623970