Liver enzymes Screening Tools

Liver enzymes Screening Tools 9. Altered sleep-wake cycle: excessive daytime sleepiness Postoperative incidence: 15-72% Urinalysis ECG CAM (The Confusion Assessment Method Instrument) with insomnia at night Onset: usually third day of hospitalization 1. Acute onset; acute change in mental status from CAM Diagnostic Algorithm Duration: <5 days, symptoms can last 3-6 mo Treatment baseline?

Feature 1: Acute onset or fluctuating course (Source: Hartford Institute for Geriatric Nursing http://consultgerirn.org) Medications 2A. Inattention difficulty focusing, easily distracted? Acute change in mental status " Low-dose phenothiazines 2B.

If present: does behavior come and go, increase or Feature 2: Inattention Outcomes Avoid barbiturates and sedatives that may increase decrease in severity Difficulty focusing, easily distracted

3. Disorganized thinking: incoherent, illogical flow of Decreased independence, loss of ability for self- agitation, confusion, and disorientation. Feature

3: Disorganized thinking ideas, switching subject? "Incoherent, illogical, unpredictable thinking determination Nursing Management

4. Altered level of consciousness: alert, hyperalert, and Feature 4: Altered level of consciousness Increased morbidity, such as falls, pressure ulcers, overly sensitive to environmental stimuli, lethargic, coma adverse effects from medications, infections, continued Vital signs and pulse oximetry Hyperalert, lethargic, stupor, or coma cognitive impairment, institutionalization Intake and output

5. Disorientation: place time, person + Diagnosis of delirium if features 1 and 2 and Increased mortality; six times more than nondelirious a Identify and remove toxic substance 6. Memory impairment: unable to remember events in either 3 or

4. Treat underlying cause hospital (Source: Inouye, S, van Dyck, C., Alessi, C., Balkin, S., patients Goal: Provide therapeutic environment

7. Perceptual disturbances: hallucinations, illusions or Siegal, A., & Horwitz, R. [1990]. Clarifying confusion: the Increased length of stay, increased acuity, increased cost Appropriate sensory stimulation misinterpretation confusion assessment method. Annals of Internal Medicine, Risk Factors m Reassure and reorient

8A. Psychomotor agitation: restlessness 113(12), 941-948.) Increased age Consistent caregivers 8B. Psychomotor retardation: sluggishness, staring into Increased severity of illness Encourage family members to be at bedside space Multiple health problems, polypharmacy Sensory aids History of dementia, depression, or previous delirium Minimize relocation Substance or alcohol abuse Simplify environment REVIEW QUESTIONS Sleep deprivation Avoid excessive medication and restraints 1. How would you differentiate signs and symptoms of delirium from dementia and depression?

Immobility Goal: Provide general supportive nursing care Answer: Sensory impairment Comfort measures Prevent complications of immobility Characteristics of Dementia, Delirium, and Depression Causes of Delirium Assist with basic needs Acute illness Communicate clearly Feature Dementia Delirium Depression Infection (UTI, URI)

Reassure and educate family Onset Medications (anticholinergics, sedatives, psychotropics, Minimize invasive procedures narcotics, H2 blockers) Prognosis Dehydration and electrolyte imbalance Evaluation/Outcome Criteria Oriented to person, place, and time Course Hemodynamic status, hypovolemia Environmental challenge (sensory overload or deprivation)

Cooperative Attention Pain Decreased agitation Memory Acute Delirium Assessment/Screening Tools for Delirium This condition is seen in postoperative electrolyte distur- Assessment Perception bance, systemic infection, renal and liver failure, overseda- Confusion Assessment Method (CAM) Psychomotor tion, and metastatic cancer.

Cognitive function: behavior Ask: Assessment Change in thinking or memory Cause Disorientation to time, especially at night m Strange thoughts Hallucinations, delusions, illusions Assess: Alterations in mood Alertness, hyperalert, lethargy, stupor, comatose Increased emotional lability Attention, ability to focus digit span, serial subtrac- Agitation tion, spelling backwards, clock drawing test Source: Dillon, P. (2007). Health assessment:

A critical thinking, case study approach. Philadelphia: F. A. Davis.

Lack of cooperation Orientation, may be disoriented to time and place Withdrawal Memory, recent and remote Feature Dementia Delirium Sleep disturbance Thinking, logical vs disorganized, rambling Alterations in food intake Perception, recognition of objects and persons Onset Diagnostic Tests Psychomotor, hypo- or hyperkinetic, unusual or Prognosis a CBC inappropriate Course m Electrolytes Attention Memory