DELIRIUM: SCREENING AND ASSESSMENT

Identification: Assessment: Interventions:

Pain Pain
• Regular pain assessment & • Regular scheduled analgesia (not prn)
monitoring • Non-pharmacological support: turning, positioning
• Use consistent pain scale • Document effect of analgesia
PREDISPOSING
RISK FACTORS: Poor Nutrition Poor Nutrition
• Dehydration/malnutrition • Fluid intake at least 1500cc/24hrs
•
Albumin or protein levels • Dietary consult:
• Cognitive
• Swallowing difficulties • Recent wt loss/gain (>10lbs in last year)
impairment
• Electrolyte/glucose imbalance • Total protein < 64 g/L and Albumin level < 35 g/L
• Over 80
• Weight on admission and prn • OT Consult for swallowing difficulties
• Chronic illness
• Multiple co-morbid Retention Retention
conditions • Determine continence ability; • In/out catheterization if suspect retention
• Sensory deficits bowel pattern • Nurse Continence Advisor consult if in retention
• Alcohol abuse • Assess for urinary retention • Regular toileting schedule (minimize use of Incontinence pads)
• Immobility • Palpate abdomen for • Initiate bowel protocol; refer to CPG on Continence
• Insomnia distention/impaction • Ensure person is well hydrated
• 5+ medications • Evaluate fluid balance/output
Restraints
Restraints • Refer to CPG on Maximizing Freedom and Least Restraint
• explore alternatives to restraints • Avoid restraints if possible. Use only if patient a danger to
whenever possible to maximize him/herself or others
functional status and safety • Involve family members/support persons

Infection/Illness (new) Infection/Illness (new)

• ongoing monitoring for UTI, • Monitor VS & O2 sats; compare to baseline (note as normal
chest infection, wound infection process of aging, temperature may remain normal)
• ↑↓ BP, postural ↓ BP
• Request appropriate diagnostic/lab tests (e.g. C&S, chest x-ray)
Immobility
• Determine pre-morbid Immobility
SCREENING TOOL: functional abilities • Encourage mobility, sitting up in chair & maintenance of ADLs
• OT/PT Consult; refer to CPG on Falls
CAMI
Sleep Sleep
Presence of features 1
• Assess for altered sleep/wake • Document changes in pattern – day/night reversal
and 2 & either 3 or 4:
cycles • implement non-pharmacological sleep promotion measures
• Use Sleep Pattern Record • intersperse activities during the day with planned rest periods
1. Acute onset &
fluctuating
course Skin Skin
• Assess for areas of skin • Pressure reducing mattress as indicated, turn q2h
2. Inattention: breakdown • Refer to Wound/Continence Nurse if wound present
• Braden Scale
-difficulty focusing
attention Sensory
Sensory • Ensure eyeglasses, hearing aids & dentures are working and
- easily distracted
• Assess for sensory deficits and used
3. Disorganized aides used • Use Pocket talker to assist with communication/assessments

Thinking:
Mental Status Mental Status
-rambling speech
• Monitor for sudden changes in • Refer to CPG on Agitated and Excessive Behaviour
- illogical flow of
ability or cognition • Identify self; use a calm/gentle approach; use cues to orient
ideas
• Other causes of behavior • Acknowledge and validate fears related to changes in cognition
• Grief, loss, emotional trauma • Use interdisciplinary interventions to support restoration of
4. Altered
Level of normal activity i.e. Volunteers/family, mobility, activities, familiar
Consciousness Medications objects and photos, routines, clocks/calendar
• Polypharmacy (>5 meds)
- agitated Medication
• Medication side effects
- alert • Review med profile with pharmacist for recent changes,
• Withdrawal – alcohol,
- lethargic adverse effects, toxicity, drug interactions
benzodiazepines, nicotine
- stuporous • Start Low, Go Slow!
• Toxicity (digoxin, dilantin)
- comatose • Assess psychotropic med response report any side effects (ie.
Metabolic ↑ anxiety/agitation; Parkinson-like symptoms, postural ↓ BP)
• Monitor for abnormal lab
results/hemodynamic status Metabolic
• Evaluate lab results and notify MD of abnormalities

Environment
Environment • Provide calm & safe environment
• Self-care ADL’s ability • Promote normal ADL routines; consistent staff
• Relocation stress (eg. Unfamiliar • Encourage family/support persons to provide support
surroundings/routine) • Provide adequate lighting and exposure to daylight

CAMI: screens for the presence of absence of a delirium

PRISME: an acronym that can assist in identifying and relieving underlying factors are modifiable and can contribute to the onset and
perpetuation of delirium; adapted from VIHA