Nursing Care: Review of Evidence-Based Practice for Delirium Care

This essay provides a comprehensive review of evidence-based practice (EBP) in nursing care, specifically focusing on the management of delirium. The introduction highlights the importance of EBP in clinical decision-making, emphasizing the utilization of research-based knowledge. The essay analyzes a case study of Mr. De Jong, who suffered from delirium, exploring best practices and non-pharmacological interventions like reorientation, mobilization, and sleep promotion. It examines risk factors, such as age, depression, and use of multiple medications, and discusses the effectiveness of multi-component interventions. The essay critiques various studies and guidelines, including those from the ACSQHC and Cochrane Library, to assess their relevance to best practice. It also addresses the importance of primary prevention and optimal sedation, emphasizing the role of nurses in improving patient outcomes. The conclusion reinforces the need for increased nurse knowledge in this area to control the progression of the disease and improve patient safety.

Running head: NURSING CARE
Nursing care
Name of the student:
Name of the University:
Author’s note

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Introduction:
Evidence based practice (EBP) is a necessary expectancy in nursing as it promotes
clinical decision making process through the utilization of research based knowledge to inform
decisions about care delivery process (Schmidt and Brown 2017). Majid et al. (2011) explains
EBP as a basis to deliver quality health care and effectively handle clinical issues in daily
practice. It pays emphasis to data extraction from prior studies and critiquing those data to decide
its application in actual practice. The main purpose of this essay is to undertake a review of the
literature to explore the evidence based surrounding the care of people with dementia. The essay
will analyze the case study of Mr. De Jong who suffered from delirium and explore best
practices related to delirium care and discuss how delirium could have been managed in this
care. The critique of the evidence will be presented to find out whether is linked to best practice
or not.
Evidence based nursing care for delirium
The case study is about Mr. Lars, a 68 years old male who has been hospitalized
recently. He used to work in bakery. However, he left his work since he had to take care of his
wife Isa, who was suffering from multiple ailments like COPD, walking difficulty due to weight
gain and diabetes mellitus. His financial condition was not good too as his sons accumulated
debts and left the city. Hanna, Mr. Lar’s daughter observed Lars to very down since the past few
months. During hospitalization, Lars was found to be agitated and restless and many non-
pharmacological protocols for delirium were initiated to reorientate him to the environment.
Delirium is a mental disorder associated with impaired cognitive function and characterized by
impaired attention, consciousness and cognition. Symptoms of confusion, restlessness and

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agitation are a common symptom in patient and Mr. Lars possessed similar symptoms too
(ACSQHC et al. 2016). The cause of delirium is multi-factorial and the review of evidence on
risk factors suggests that aged greater than 70 years, visual impairment, use of 3 or more
medications, depression and use of physical restraints are common risk factors of delirium (). In
case of Lars, age is risk factor because he is 68 years old. In addition, being in depressed state
because of his wife condition, financial struggles and loss of contact with his sons might also
have contributed to delirium risk. Kalish, Gillham and Unwin (2014) revealed that risk factor of
delirium in hospitalized elderly patients include cognitive impairment, elevated level of blood
urea nitrogen/serum creatinine ratio, severe illness and vision impairment. Severe illness, being
in mechanical ventilation for more than 24 hours and high rate of creatinine levels of Mrs. Lars
made the nurse to predict the risk of delirium.
According to Perez-Ros et al. (2018), delirium is a condition that affects about 15-50%
of hospitalized elderly patients. In elderly individuals like Mr. Lars, preventing delirium is
important as it could lead to functional decline, loss of independence, longer period of hospital
stay and even death. Preventive strategies are needed to control the progression of disease and
promote safety of patient. The recommendation for delirium care mostly suggests the
effectiveness of multi-component intervention in controlling delirium episodes. Although both
pharmacological and non-pharmacological treatment options are available to treat delirium,
evidence shows that pharmacological intervention should be initiated for those patients who
engage in self-harm too (Kalish, Gillham and Unwin 2014). In the case study, no
pharmacological intervention was implemented and this decision is appropriate because Mr. Lars
symptom was not that severe to require pharmacological intervention. The study by
Barbateskovic et al. (2019) reported about pharmacological intervention such as use of anti-

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psychotic medications for management of delirium in intensive care patient. A systematic review
of randomized controlled trials which investigated on the effects of pharmacological prevention
of delirium and this study also revealed very low evidence for the use of pharmacological
intervention. This intervention is used in exceptional cases only where non-drug methods of
delirium treatment has failed. This study ranks under highest level in evidence hierarchy.
However, lack of methods to minimize random errors is one of the limitation of the study.
The nurse implemented several non-pharmacolgiical interventions to manage symptom
of Mr. Lars. This included reorientation to the environment, mobilization activities and ensuring
range of motion exercise. The nurse’s decision is in relevance with best practice guidelines as
these paper recommends use of non-pharmacological interventions like early mobilization,
reorientation, risk factor assessment and balancing sleep-wake cycle for the management of
delirium too (Barbateskovic et al. 2019). The Delirium Clinical Care guideline by ACSQHC
(2016) states that multi-component interventions can reduce the occurence of delirium and it’s
associated complication. The strength of this guideline is that it provides separate quality
statement for patients and clinicians. This resource informs health care professionals regarding
the steps to prevent delirium. This includes mobility activities, promoting sleep, visual aids, pain
assessment, oxygen therapy, correction of malnutrition and stimulating cognition. However, as
this guideline does not support the rationale behind the use of various multi-component
intervention, individually reviewing the effectiveness of each one of the treatment is critical to
ensure quality care and better understanding about delirium management.
As Mr. Lars was found to be having delirium symptoms post hospitalizations, those
papers were reviewed which had hospitalized older patients with delirium as the sample group.
The study by Inouye et al. (1999) randomized controlled to investigate about the topic. The study

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was done with 852 patients older than 70 years of age and the intervention consisted of
standardized protocols that managed six risk factor of delirium. This included sleep impairment,
immobility, hearing impairment, dehydration, visual impairment and cognitive impairment. The
intervention was implemented by six specialists. To reduce cognitive impairment, cognitive
stimulating programs like word games and discussion of current event was done for three days.
Sleep protocol included warm drink at bedtime, noise reduction strategies and music.
Mobilization activities covered ambulation and range of motion exercises three times daily.
Dehydration protocol included encouragement of oral fluid intake. The assessment of primary
outcomes of delirium revealed that 9.9% of the intervention group developed delirium compared
to 15% of the control group. The number and duration of delirium episode significantly reduced
too. Hence, this study clearly suggests the importance of primary prevention of delirium during
treatment. The result is reliable because RCT was used which minimizes bias by means of
randomization and blinding techniques. This evidence can inform nurses about primary
prevention of delirium. Recent meta-analysis done by Hshieh et al. (2015) confirms too that non-
pharmacological interventions for delirium is effective in preventing delirium incidence and
length of hospital stay.
Taking cues from above evidence, one drawback seen in case of Lars treatment is that
preventive treatment was not started earlier. For example, he needed dehydration treatment from
the beginning, but change in nitrogen to creeatine ration suggests no implementation of
dehydration. This should have started earlier to prevent symptoms of delirium. There were many
interventions that were started by nurse post detection of delirium. Hence, the efficacy of
intervention implemented post diagnosis is important too. In the case study, the nurse used
mobility strategies, communication strategies and range of motion exercises. Mobilization is a

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crucial strategy and it is part of clinical care guideline for delirium. According to Grover and
Avasthi (2018), mobilization is important to prevent complications associated with the condition.
Patients with delirium are at risk of secondary complications like falls, bedsores, functional
impairments, oversedation and poor bowel control. Mobilization is beneficial in supporting Mr.
Lars to mobilize at the earliest.
From the critical analysis of the care provided to Lars post hospitalization, it has been
found that he was in mechanical ventilation, which is the most common risk factor of
hospitalization. However, no sedative was provided to him. As the onset of delirium was seen
post mechanical ventilation, Mr. Lars is at risk of long-term psychosocial functioning too. Bulic,
Bennett and Shehabi (2015) explain that sedation practices during hospitalization and use of
sedations strongly determines rate of neurobehavioral disorder in patients. The study gave
examples of studies that reported about association between sedatives and occurrence of
delirium. Burry et al. (2014) reported about the link between sedation and adverse outcomes such
as delirium, long term psychological symptoms and cognitive impairment. Hence, as part of
preventive treatment, there is a need to give trainings and knowledge related to the importance of
achieving optimal sedation for critically ill patients. Achieving optimal sedation can be
challenging due to the fluctuating condition of patient. However, review of evidence based on
optimal sedation administration strategy is important to minimize the possibility of drug
bioaccumulation and minimizing the potential for oversedation and its adverse consequences.
The potential of daily sedation interruption should be reviewed by current nurses and critical care
staffs to minimize risk of delirium for hospitalized patients like Mr. Lars. Mobilization is a part
of most multi-component intervention strategies for patient with delirium. Since the study used

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before and after quasi-experimental research design, the efficacy and validity of the outcome is
further confirmed (Holt, Young and Heseltine 2013).
The nurse implemented many motion exercises to control symptoms of Mr. Lars. The
significance of this strategy is understood from the review of evidence by Karadas and Ozdemir
(2016). The study aimed to evaluate the impact of range of motion exercise in preventing
delirium. The relevance of this paper to the case study is that the study included participants aged
more than 65 years in the intensive care unit with mechanical ventilation. The participants were
randomly allocated to intervention group and control group. After the analysis of the rate of
incidence of delirium post the intervention, it was found that duration of delirium was 8.5% in
the intervention group compared to 21.3% in the control group. The difference in incidence
percentage clearly shows how far motion exercise can control symptoms of delirium. However,
the evidence also demonstrated that providing only one type of exercise may not give the desired
result. The study recommended use of individualized therapy based on patient’s tolerance level.
The physiotherapist can coordinate with the intensive care team to give idea about effective
exercise regimen. Sleep intervention is important as part of multi-component intervention for
delirium. But in case of Mr. Lars, no attention to promotion of sleep was given. The best practice
guidelines by ACSQHC (2019) suggest the need to maintain sleep patterns with appropriate day
lighting for patient. This is particularly important for patients with delirium in the ICU as
Kamdar et al. (2016) gives the evidence that sleep deprivtion is a common problem in ICU
patient and sleep promotion has the potential to improve symptoms.
To conclude, the essay gave an insight into the risk factors of delirium and the common
risk factor that was found for Mr. Lars. Through the analysis of the best practice evidence and
the treatment given to Lars, it can be said that he did not received best primary intervention for

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prevention of delirium. However, robust evidence was found for effectiveness of multi-
component intervention. There is a need to increase nurse knowledge in this area so that
progression of disease is controlled.
References:

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ACSQHC (The Australian Commission on Safety and Quality in Health Care) 2016. Delirium
Clinical Care Standard to improve care and prevention. Retrieved from:
https://www.safetyandquality.gov.au/media_releases/delirium-clinical-care-standard-to-improve-
care-and-prevention
ACSQHC 2016. Delirium Clinical Care Standard July 2016. Retrieved from:
https://www.safetyandquality.gov.au/sites/default/files/migrated/Delirium-Clinical-Care-
Standard-Web-PDF.pdf
ACSQHC 2019. A better way to care : Safe and high-quality care for patients with cognitive
impairment or at risk of delirium in acute health services. Retrieved from:
https://www.safetyandquality.gov.au/sites/default/files/migrated/A-better-way-to-care-Actions-
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