Dimensions of Adult and Intensive Care: Delirium Prevention Report

This report examines non-pharmacological interventions for preventing delirium, focusing on a case study of a 62-year-old patient admitted to the ICU following mitral valve replacement. The report explores the nature of delirium as a neurological disorder, including its symptoms (agitation, hallucinations, lethargy) and the challenges in diagnosis and treatment. It highlights the limitations of pharmacological interventions and emphasizes the importance of non-pharmacological strategies such as noise reduction, sleep protocols, and mobilization. The report emphasizes the need for improved nursing management, education, and multi-component interventions to enhance patient outcomes and reduce the incidence of delirium in critical care settings. It underscores the importance of family involvement and systematic implementation of evidence-based practices to provide comprehensive patient care.

DIMENSIONS OF ADULT AND INTENSIVE CARE PRACTICE

TABLE OF CONTENTS
INTRODUCTION.......................................................................................................................1
KNOWLEDGE OF THE PATHOPHYSIOLOGY.....................................................................2
OVERVIEW OF DELIRIUM AS A NEUROLOGICAL DISORDER......................................2
IMPACT OF PHARMACOLOGICAL AND NON-PHARMACOLOGICAL
INTERVENTIONS .....................................................................................................................4
IMPACT OF NON-PHARMACOLOGICAL INTERVENTIONS ...........................................5
ROLE OF NURSING MANAGEMENT....................................................................................7
RECOMMENDATIONS FOR NURSING MANAGEMENT...................................................7
CONCLUSION............................................................................................................................8
REFERENCES..............................................................................................................................10

Prevention of delirium through using non- pharmacological interventions
INTRODUCTION
This project will mainly focus on exploring all the literature behind the non pharmacological
interventions which will help in prevention of delirium. This research will also help in
recognizing any unique interventions and will also lay emphasis on the impact of delirium has on
patients. This case study will also focus on importance of nursing management, role of nurses in
implementation of all the aspects of non pharmacological intervention which further helps in
intensive care of patients (Rodin and Flaherty, 2018). This case study is about a 62 years old
patient who is suffering from delirium who has been admitted to ICU for replacement of minimal
invasive Mitral Valve.
OVERVIEW OF CASE STUDY
Mr L is a 62 year old male patient who has been admitted to Intensive care unit sedated
and ventilated with propofol as well as alfentanil, after a minimal invasive Mitral Valve
replacement .As per normal protocol post -operative patients with mitral valve replacement
extubate after 6 hours if they are hemodynamically stable (Patient anonymity is preserved by
calling MR L in order to comply with the NMC (2015 )code of conduct of confidentiality). Mr L
had no postoperative complication, observations were normal, sedation off and was opening his
eyes but seemed to be in distress. Pain was controlled with epidural as patient had a thoracotomy
incision. Four hourly sensory and motor block assessment was done to check the efficacy of
epidural .The decision was made by medical team to extubate after 7 hours as patient seemed to
be distressed with the tube. After extubation Mr L started to get agitated. The next morning his
agitation worsened, he started to hit staff and it was difficult to manage him in bed. For safety of
the patient and staff haloperidol, 5mg given intravenously with no effect. Mr. L Body Mass
Index was 31.5 with good health and hight and had no previous mental health history. Thus,
decision made by the staff were based on discussion with nurses as well as medical team to re-
intubate Mr L for maintaining his safety. Sedation was held daily. CAM_ICU (Confusion
Assessment Method for Intensive Care unit) was positive on sedation hold, therefore as per
doctors advice clonidine infusion were commenced and decided to extubate the patient on 3rd
day. PRN haloperidol and clonazepam were also prescribed .Patient agitation got worsened,
mittens were needed on both hand, on unmanageable occasion security were present . Family
1

were getting very emotional and distressed. Psychiatric reviews were made , quetiapine was
added to prescription at night .Even ,after two weeks there were no changes in his delirium,
nurses and doctors had a meeting to decide how to control his agitation. Apart from the
pharmacological treatment , non pharmacological intervention given to the patient were limited.
It was not possible to discharge the patient to the ward from intensive care due to the severity of
agitation.
OVERVIEW OF DELIRIUM AS A NEUROLOGICAL DISORDER
Delirium can be defined as a mental health condition which is mostly experienced by the
patients who are normally admitted in Intensive Care unit (Ballard et al. 2017). Delirium has
been further explained below:
Disease: Delirium
Signs and Symptoms: Main symptoms of delirium are agitation, hallucination, lethargy,
sleepiness. In this case study patient was Starting to get agitated and his agitation was increasing
continuously because of this he use to hit the staff for no reason. He was continuously becoming
unmanageable both physically and mentally. In Mr. L condition it was clear that he had
hyperactive delirium and it was quite evident due to his agitation (Bannon et al. 2016).
Sometimes adverse reaction of medicines also causes delirium.
Investigation and diagnosis: Normally delirium is diagnosed on the basis of previous mental
health history but Mr. L had no mental health history Beresford et al. (2018). So in his case
various mental test were conducted in order to understand mental health status. Mental health
assessments are done to understand their health problems, current medical conditions and
underlying causes of this condition. Most of the time delirium is unpredictable in nature due to
fluctuating nature of an individual but increasing agitation, confusion becomes main reasons due
to which it is diagnosed (Salluh et al.,2015).
Treatment: Once delirium is detected, its treatment is started by eliminating all the risk factors,
precipitating factors like in Mr. L's main factor was his medications (all the medicines that were
given to him for both his delirium and related to his recovery after his operation). There is no
particular ICU treatment for delirium but there are various strategies which helps in reducing this
disease.
It is quite important to understand the type of strategy that is being applied or under on
2

the delirium patients as all the strategies are not effective on all the patients. With the ongoing
treatment it is quite important to brief the patients family about this disease like who it affects the
mental health of the patient, how it can be reduced, ways to look after the patient etc. Brenner
and Piehl (2016).
As per a research conducted by Slooter, (2017), the prevalence of delirium ranges in
between 60-80% especially in ventilated patients as well as in non-ventilated patients, it is in
between 40 -60%. It has been observed that delirium is greatly a long term cognitive impairment.
Delirium can also be categorized as hypoactive, hyperactive and mixed (Nagaratnam,
Nagaratnam and Cheuk, 2017). Hypoactive can be defined as a condition where mixed type of
delirium are seen which are mostly unpredictable because of its fluctuating nature (Vainieri and
et al., 2019). Hyperactive delirium can be defined as a category where patients are normally
agitated (Tolkachjov and Wetter, 2017). As per the view of DeAngelis (2016), hyperactive
patients are normally treated with much higher dose of sedatives and other than this, mechanical
ventilation is also provided to them which helps in stabilizing cognitively impaired state.
According to Ballard et al., (2017), there are mainly two groups of risk factors which are
precipitating and predisposing. Predisposing factors can be defined as patient's baseline
vulnerability and precipitating factors can be defined as hospital's vulnerability which also
includes noxious injuries (Tolkachjov and Wetter, 2017). Delirium can be detected by
determining the main root cause and all the risk factors associated with it (Kim, Chun and Kim,
2018). As per the condition of Mr. L it had also been observed that he was a hyperactive delirium
patient. The risk factors of delirium was due to precipitating factor especially due to medications
like ropofol aand alfentanil that were being given to him.
As per the view of Dayabandara et al., (2017), it has been observed that non
pharmacological and pharmacological interventions plays a vital role in preventing delirium. As
per the view of Morrin and et al., (2018), has also explained further that pharmacological
strategies recommendation to minimize delirium are quite limited which becomes one of the
reason due to which delirium happens. As per the case study it has been observed that Mr L was
admitted for almost 35 days in ICU and for all those days he was treated with pharmacological
strategies they did not try to use non pharmacological interventions other than daily visit from
his family which clearly explained that complete medical team and nurses did not have adequate
3

knowledge about the same.
According to Norris and et al. (2016) there are more than 28 non-pharmacological
interventions and most common type of interventions used are reorientation, mobilisation, noise
reduction, music therapy, education of nurses and sleep protocol. Out of all the 28 interventions
best type of intervention are noise reduction, mobilisation and sleep protocol which helps in
preventing delirium.
On the contrary, Rodakowski and et al. (2015), says that it was quite effective as
effectiveness of non pharmacological interventions prevent delirium in old people. Besides this
multi components interventions helps in preventing delirium but not treating it. This was
observed from the study conducted in 3329 abstracts (Rodakowski et al., 2015). In this 80
reviews were evaluated and 26 were included and 54 were excluded. The articles selected were
published between 1996 -2014. The multi component interventions are providing bright light, ear
plugs and eye mask for sleep wake rhythm. Apart from it, there are many others as well such as
providing music therapy, bowel management, etc. It has been said by Richardson et al. (2015),
that in order to gather data regarding non pharmacological treatment for delirium it is the first
systematic review and meta analysis. However, he was unable to identify that how each
intervention contributes in it.
By analysing the above studies, there are some facts that focused on benefits of multi
component intervention that helps in preventing delirium. Here, all interventions that has been
evaluated in studies might prove useful in providing care services to Mr. L. Alongside, there are
no side effects of such interventions on patients like Mr.L. In context to case study, the sleep
protocol was implemented from 13.30 -1500 p.m. and 22.00 – 6.00 a.m. It was also found that
the staff did not have any knowledge about multiple non pharmacological interventions. Thus,
due to lack of knowledge among the professionals, proper measures were not taken (Barret et al.,
2013). Furthermore, it has been demonstrated that after studying the case study, multiple
interventions are effective in preventing delirium and must be implemented systematically to
patients like Mr. L.
Firstly, protocols including instructions or policies must be executed regarding proper
usage of multiple interventions which consists of mobilization, educating nurses, etc. In addition
to it, the family must also be involved in providing care services to patients. The second thing is
4

that it is very necessary to educate nurse (Vainieri et al., 2019). It involves many other
interventions as well. This can be provided by organizing one to one session, through posters,
etc. It is analysed that patient reassurance and reorientation is evitable and board term. Thus,
nurse should develop an effective strategy to attain her goals. As a result by implementing new
intervention changes in health care setting can be made. The nurse can accept and support
change.
IMPACT OF NON-PHARMACOLOGICAL INTERVENTIONS
According to Riddell et al. (2015) delirium is one of the invasive type of mental health
disorder where the non-pharmacological interventions are facilitated for the prevention and
treatment. A combination of both quantitative and qualitative studies supported in knowing the
advantages of taking this type of intervention. This is one of those effective methods to safeguard
the critically ill patients such as Mr.L from the case study. For instance, the noise reduction must
be encouraged around patients that are affected from delirium. In addition to this, the sleep cycle
would be easily maintained through using ear plugs and giving eye masks as dim lightening is
preferred in the ICU (Fleming et al., 2016). This is only possible when the nurses are given
proper training and imparted teachings to assure quality and delivery of services involving music
therapy and physiotherapy affected form any neurological disorder.
Furthermore, Brenner and Piehl (2016) stated that the adoption of tools like using ear
plugs, eye masks and taking sessions for therapy has been proved beneficial to provide patient
centred care. The patent's tolerance levels has been improved and they become more supportive
towards nurses and other professionals. On the other hand, Fleming et al. (2016) elucidated that
the methods suggested are generic in nature and are adopted by all the patients and are under cost
effective but not perfect for the patients of Delirium. There is implementation of a single centre
randomized control study by Cohen-Mansfield (2018) that has shed light on the effectiveness of
using such methods including music, ear plugs and masks for making the patients calm,
cooperative and focused. The benefits have reflected on enhanced levels of sleep with a good
circadian rhythm. Here the staff working in the ICU must be held responsible in maintaining the
patient centred care under the responsible and ethical standards. It has been found out that lack
of structured interventions leads towards the path of anxiety and claustrophobia among the
5

patients with delirium and using the tools like plugs or mask would only improve comfort levels
(Inouye et al., 2014). It also shed light on the need to impart education to the professionals about
dealing with patients with more organized ways.
In addition to this, Moore et al. (2019) elucidated that the purpose behind using such
tools is only related to the treatment and recovery plan of patients and must be promoted in all
the healthcare institutions. However, the causes behind the sleep deprivation must be recognized
to assess the overall conditions of the patients who are affected from delirium. There is also the
unfamiliarity in context to the hospital environment for the patients and the dilemma attached
with the place or location for the patients and their families. From this research, the non
pharmacological intervention are always promoted by the professionals and the nurses are given
training to monitor and create a more friendly atmosphere for speedy recovery. Hshieh et al.
(2019), shed light on the effects of healthcare protocols on the sleep patterns and its factors. This
emphasis on patients' capacity in dealing with daily chores and tasks to be performed on daily
basis. In addition to that, delirium incidence has become halved and approximately 40 % cases
has been reduced in an acute hospital setting through the introductory program named as
delirium prevention protocol. It is mainly developed for the families who would receive
education and learning sessions about delirium and the associated signs, symptoms, prognosis.
Here the administration of the hospitals must provide eye ware, small hearing devices and more.
ROLE OF NURSING MANAGEMENT
There is a need to understand that it is very necessary to educate nurse. It involves many
other interventions as well. This can be provided by organizing one to one session, through
posters, etc. It is analysed that patient reassurance and reorientation is editable and broad term
(Portoghese et.al., 2015). Thus, nurse should develop an effective strategy to attain her goals so
that all the delirium conditions can be improve.
As a result by implementing new intervention changes in health care setting can be made.
The nurse can accept all kind of challenges and not only this they can also support changes. As
per the views of Portoghese et al. (2015) it is necessary to educate nurse so that any danger and
implication is avoided in it. The nurse should be educated about risks, dangers and implications
of the development of delirium while stressing that patient becomes increasingly difficult to care
for once delirium occurs. This is important but never implemented due to adoption of traditional
6

teaching methods, absence of accountability and transparency between staff and administration,
no up-gradation of skills set and more, the management is unable to give training (Cavallazzi et
al., 2012).
There is another reason due to which nurse resists is lack of time in their shift as they are
not able to completed added task. In some intervention it is concluded that while working in
protocol it took 10 -15 minutes extra for nurse to implement (Cherry and Jacob, 2016). The multi
disciplinary approach determine which non pharmacological protocol prevent delirium. This is
because the bed side nurse is in constant touch with patient.
In a qualitative survey conducted Masters (2018) analysed that in order to determine
management of delirium by doctors and nurses in intensive care revealed transparency of
delirium without any protocol. Here, the nurse acknowledges diverse criteria that lead towards
conflict among them where interventions are more appropriate. Hence, implementing specific
protocol for non pharmacological interventions for managing delirium is effective and efficient.
RECOMMENDATIONS FOR NURSING MANAGEMENT
The recommendations included about following the guidelines outlined by the National
Institute for Clinical Excellence (NICE). This has promoted the use of CAM-ICU tool for
systematic assessment of delirium onset in the patients especially the elderly (El Kerdani and
Nimmo, 2016). Moreover, it would be useful in using the mentioned tools for recognizing about
the symptoms and signs for knowing the progression and mental conditions of the affected
patients. There is also need for establishing an ABCDE bundle to bring proper changes in both
the functional and neurological outcomes for the mechanically ventilated patient as given in the
case study (Costa et.al., 2017). Here, the bundle has incorporated D for delirium which reflected
upon the daily assessment of delirium affected patients. The adoption of tools to help the patients
having sound sleep and keep a check on the sleep patterns, early mobilization with complete
participation from the members of the family. Along with this, the Society of Critical Care
Medicine' Pain Agitation and Delirium (PAD) had been created to promote about the awareness
of ICU PAD Care Bundle, which has been considered as one of the valid assessment tools for
delirium (Devlin et.al., 2018). Primarily, it helps in encouraging the adoption of the non
pharmacologic interventions. It has also been demonstrated that such interventions have been
7

proved inconsistent and ambiguous while trying to implement at the organizational levels. Here
the staff must be trained professionally to give qualitative levels of delivery of services.
In regard to this, the barriers and obstacles for educating professionals includes using
traditional methods for treatment, communication gaps, absence of skills set in nurses that are
required to treat critical case studies etc. while giving the treatment plan to the patients. Here the
pathophysiology and anatomical structure of the patient who are ventilated and are mechanically
dependent must also be considered. The focus is on giving a structured and strategic treatment
plan to make the patients. The patients and families have also received result oriented strategies
to make the nurses understand about the well being of the overall atmosphere.
CONCLUSION
It could be concluded from the above part that if doctors and practitioners are using non-
pharmacological interventions then it will be of extreme importance in order to prevent delirium.
However, many of the studies done are highlighting the risk of bias for this type of intervention
rather most of them advising for using the non- pharmacological intervention for an intensive
care setting. The most of the studies said about benefits for this system like that of low cost risk
and low cost strategies. But its challenge will include that of developing which sort of protocol
should be followed for this intervention. There are also suggestions in some of the studies like
having multicomponent intervention rather than only one single one. Some of the studies will be
supporting the regular reassurance of awareness for surroundings, education for staff, their
reorientation, mobility into the protocol created and then noise reduction as well. It could also be
summarised that the multidisciplinary approach would be suggested for reviewing the
intervention for more benefits so that it could be implemented within staff specified units.
There are about 80% cases of delirium which are faced by patients into intensive care
with the help of implementation of non- pharmacological approached. So there is chance of
reduction into this particular percentage of affected patients and thus lowering down the health
burden of practitioners and improving patient’s life quality for them are their family. The above
case study is stating the complexity which patient of delirium is facing which will be linked with
the intervention and the problem present in proper application of care which is leading towards
improper management.
8

REFERENCES
Books and Journals
Ballard, C. et al. (2017). Impact of antipsychotic review and non‐pharmacological intervention
on health‐related quality of life in people with dementia living in care homes: WHELD
—a factorial cluster randomised controlled trial. International journal of geriatric
psychiatry. 32(10). pp.1094-1103.
Bannon, L. et al. (2016). Impact of non-pharmacological interventions on prevention and
treatment of delirium in critically ill patients: protocol for a systematic review of
quantitative and qualitative research. Systematic reviews. 5(1). p.75.
Barr, J. et al. (2013). Clinical practice guidelines for the management of pain, agitation, and
delirium in adult patients in the intensive care unit. Critical care medicine. 41(1). pp.263-306.
Beresford, B. et al. (2018). Pharmacological and non-pharmacological interventions for non-
respiratory sleep disturbance in children with neurodisabilities: a systematic
review. Health technology assessment, pp.1-295.
Brenner, P. and Piehl, F. (2016). Fatigue and depression in multiple sclerosis: pharmacological
and non‐pharmacological interventions. Acta Neurologica Scandinavica, 134, pp.47-54.
Cavallazzi, R. et al. (2012). Delirium in the ICU: an overview. Annals of intensive care.2(1).
p.49.
Cherry, B. and Jacob, S.R. (2016). Contemporary nursing: Issues, trends, & management.
Elsevier Health Sciences.
Cohen-Mansfield, J., 2018. Non-pharmacological interventions for persons with dementia: what
are they and how should they be studied?. International psychogeriatrics. 30(3). pp.281-
283.
Costa, D.K. et.al. (2017). Identifying barriers to delivering the ABCDE bundle to minimize
adverse outcomes for mechanically ventilated patients: a systematic
review. Chest. 152(2). p.304.
Dayabandara, M. et al. (2017). Antipsychotic-associated weight gain: management strategies and
impact on treatment adherence. Neuropsychiatric disease and treatment, 13, p.2231.
DeAngelis, L.M., (2016). Neurologic complications of cancer. Holland
‐Frei Cancer Medicine,
pp.1-15.
Devlin, J.W. et.al. (2018). Methodologic Innovation in Creating Clinical Practice Guidelines:
Insights From the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation,
Delirium, Immobility, and Sleep Disruption Guideline Effort. Critical care
medicine.46(9). pp.1457-1463.
Doehner, W. et al. (2018). Heart and brain interaction in patients with heart failure: overview and
proposal for a taxonomy. A position paper from the Study Group on Heart and Brain
Interaction of the Heart Failure Association. European journal of heart failure. 20(2).
pp.199-215.
9

El Kerdani, T. and Nimmo, A., 2016. Integrating conventional and CAD/CAM digital techniques
for establishing canine protected articulation: a clinical report. The Journal of prosthetic
dentistry. 115(5). pp.515-519.
Fleming, P.S. et al. (2016). Non‐pharmacological interventions for alleviating pain during
orthodontic treatment. Cochrane Database of Systematic Reviews. (12).
Gwernan‐Jones et al. (2016). End‐user involvement in a systematic review of quantitative and
qualitative research of non‐pharmacological interventions for attention deficit
hyperactivity disorder delivered in school settings: reflections on the impacts and
challenges. Health Expectations. 19(5). pp.1084-1097.
Hshieh, T.T. et al. (2019). The Better Assessment of Illness Study for Delirium Severity: Study
Design, Procedures, and Cohort Description. Gerontology. 65(1). pp.20-29.
Inouye, S.K. et al. (2014). Delirium in elderly people. The Lancet. 383(9920). pp.911-922.
Kim, M.S. et al. (2018). The Incidence and Related Risk Factors of Delirium in the Older
Inpatients with Neurological Disorders in a Tertiary Hospital. Korean Journal of Adult
Nursing. 30(3)., pp.255-265.
Lee, H.J. and Kim, S.R. (2018). Factors Influencing Delirium in Neurological Intensive Care
Unit Patient. Korean Journal of Adult Nursing. 30(5). pp.470-481.
Masters, K., 2018. Role development in professional nursing practice. Jones & Bartlett Learning.
Moore, D.A. et al. (2019). Non-pharmacological interventions for ADHD in school settings: an
overarching synthesis of systematic reviews. Journal of attention disorders. 23(3).
pp.220-233.
Morrin, H. et al. (2018). Systematic review of the efficacy of non-pharmacological interventions
in people with Lewy body dementia. International psychogeriatrics. 30(3). pp.395-407.
Nagaratnam, N. et al. (2017). Acute Delirium in the Elderly: Diagnosis and
Management. Geriatric Diseases: Evaluation and Management, pp.1-8.
Norris, S.L. et al. (2016). Long-term non-pharmacological weight loss interventions for adults
with type 2 diabetes mellitus. Sao Paulo Medical Journal. 134(2). pp.184-184.
Portoghese, I. et al. (2015). A multilevel investigation on nursing turnover intention: the cross‐
level role of leader–member exchange. Journal of nursing management. 23(6). pp.754-
764.
Richardson, M. et al. (2015). Non-pharmacological interventions for
attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic
reviews of quantitative and qualitative research. Health Technology Assessment
(Winchester, England). 19(45). p.1.
Riddell, R.R.P. et al. (2015). Non‐pharmacological management of infant and young child
procedural pain. Cochrane Database of Systematic Reviews. (12).
Rodakowski, J. et al. (2015). Non-pharmacological interventions for adults with mild cognitive
impairment and early stage dementia: An updated scoping review. Molecular aspects of
medicine. 43. pp.38-53.
Rodin, M.B. and Flaherty, J.H., (2018). Delirium Prevention: Update on Multidisciplinary, Non-
drug Prevention of Delirium Among Hospitalized Elderly. In Delirium in Elderly
Patients(pp. 111-123). Springer, Cham.
10

Salluh, J.I. et al. (2015). Outcome of delirium in critically ill patients: systematic review and
meta-analysis. Bmj.350. p.h2538.
Slooter, A.J.C., (2017). Delirium, what’s in a name?.
Tolkachjov, S.N. and Wetter, D.A. (2017). Schnitzler Syndrome With Delirium and Vertigo: The
Utility of Neurologic Manifestations in Diagnosis. Journal of drugs in dermatology:
JDD. 16(6). pp.625-627.
Vainieri, M. et al. (2019). The role of collective labor contracts and individual characteristics on
job satisfaction in Tuscan nursing homes. Health care management review. 44(3).
pp.224-234.
11