Delirium

Main ideas and lessons about delirium (from the lecture)

Delirium is taught as a clinical syndrome in medical and nursing education.

Primary learning outcomes

• Explain the medical concept of delirium.
• Explain the concept of delirium nursing care.

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Definitions / core features

The lecture presents three definitions (exact wording unclear from subtitles), emphasizing a shared key feature:

• Decreased consciousness that occurs rapidly (fast onset) over a short period.

Decreased consciousness can lead to additional problems, including:

• Cognitive and thinking impairment (memory/thought problems)
• Additional signs and symptoms described in detail later

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Epidemiology (how often delirium occurs)

Approximate percentages reported by patient group:

• 10–15% of general surgery patients
  • Delirium as an effect of anesthetic drugs
• 15–25% of general medical care patients
  • Associated with the underlying disease process in regular hospital wards
• ICU surgical patients: ~30%
  • Often after major surgery and often after leaving the operating room
• ICCU (cardiac-related intensive care): 40–50%
  • Especially for patients monitored in heart-related ICU settings
• Post-cardiotomy patients: ~90%
  • Particularly after heart surgery/open thorax

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Causes / contributing factors of delirium

Causes are grouped into:

1. General medical conditions
2. Medication-related factors
3. Additional symptom triggers (mentioned after the main categories)

1) General medical conditions (examples)

• Infections
  • Including effects on hemodynamics or spread affecting the brain/nerves (e.g., sepsis)
• Metabolic disorders
  • Hypoglycemia
  • Hypernatremia / hyponatremia
  • Hypocalcemia
  • Dehydration
  • Mechanism described: fluid/electrolyte problems → impaired circulation/oxygenation/oxygen exchange → delirium
• Organ disorders
  • Kidney failure, liver failure
  • Hypoxia (not only from kidney/liver failure, but from multiple diseases)
  • Kidney failure explanation: kidneys normally filter/remove waste; failure leads to waste accumulation in blood, interfering with conscious function
• Neurological disorders
  • Stroke
  • Head trauma
  • Brain tumors
  • Epilepsy
  • Rationale: disturbance in brain/CNS structures involved in regulating consciousness (or related cerebrospinal structures)
• Severe pain / terminal chronic illness

2) Medications and medication events

• Side effects of drugs, including:
  • Opiate drugs
  • Benzodiazepines
  • Corticosteroids
  • Digoxin (subtitle spelling unclear; appears as “dadigoxin”)
• Drug poisoning / overdose
  • Mentions narcotics and drug overdose
• Stopping or reducing medications
  • Specifically: drug withdrawal
  • Examples: stopping/reducing painkillers, nicotine, narcotics, or alcohol

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Signs and symptoms (early/typical delirium manifestations)

1. Disturbed consciousness
   • Ranges from very alert → sopor/sleepy → semi-comatose/comatose
2. Extreme distraction
   • Difficulty focusing when spoken to
   • Disoriented to time and place
3. Disorders of abilities, reasoning, and goal-directed behavior
   • Actions become uncontrollable, illogical
4. Sleep–wake cycle changes
   • Waking at night / sleeping at unusual times
5. Emotional instability
   • Easily angered, irritable, emotional lability
6. Misperception of environment
   • Hallucinations (seeing/hearing things others don’t)
7. Autonomic nervous system manifestations
   • Tachycardia
   • Sweating
   • Dilated pupils
   • Increased blood pressure
8. Speech changes
   • Incoherent conversation; speech may become unconnected
9. Short-term memory disturbance
   • Inability to remember recent information
10. Attention/focus problems
11. Motor/balance problems
    • Poor coordination/disorganization of muscles (as described)

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Course/prognosis and medical therapy (management focus)

• Delirium is described as a symptom resulting from another underlying disease.
• It can occur in psychiatric settings too, including contexts such as drug withdrawal.

If the precipitating cause is not treated:

• Consciousness may decrease further.

Treatment principle

Treat the cause (not only symptoms).

Cause-based treatment (examples implied by the lecture)

• If due to metabolic disorders / electrolyte imbalance:
  • Provide the missing electrolytes
• If due to infection (e.g., sepsis):
  • Treat sepsis/infection
• If due to vascular/brain-related disorders:
  • Treat the brain/vascular cause

Expected symptom timeline

• Symptoms may disappear within 3–7 days
• May disappear completely within 2 weeks
• Depends on the patient condition and the cause

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Nursing responsibilities and assessment (methodology/instructions)

Step 1: Assessment

The lecture instructs nurses to:

• Perform an assessment, because delirium is closely related to physical factors.
• Assess using Gordon’s patterns (11 patterns referenced).
• Conduct a complete physical examination.

Core assessment items (detailed)

• Level of consciousness
  • Qualitative: from compos mentis to coma
  • Quantitative: using a Glasgow Coma Scale (subtitle says “glass cave scale”)
• Memory
  • Short-term memory
    • Remembering simple items (e.g., three object names)
    • Remembering the last incident before entering hospital
  • Long-term memory
    • Parents’ names, spouse’s name, where the patient came from
• Attention/focus
  • Whether the patient can focus during conversation or is easily distracted
• Speech and language skills
  • Whether the patient can express needs coherently
  • Note: impaired consciousness can cause disturbed verbal communication
• Sensory perception
  • Investigate hallucinations
  • Structured approach described:
    • Determine type of hallucination (five types mentioned)
    • Identify content
    • Assess frequency
    • Difficulty noted: patient responses may vary due to impaired consciousness
• Delusions
  • Example: believing they are refreshing themselves while recovering from drug intoxication/overdose
• Delirium measurement instruments/tools
  • Tools to assess agitation/need to wake patient (mentions RAS/RA)
  • Tools for delirium and dementia, including:
    • An informal questionnaire on cognitive decline in the elderly
  • Delirium Screening Tool (assess severity)
  • Tools for cognitive function, motor symptoms, and related risk factors

Step 2: Nursing diagnoses and linked issues

• Nursing issues depend on the causative factors; delirium always includes decreased consciousness.

Examples of nursing diagnosis targets mentioned:

• Gas exchange disorder
  • If cause includes hypovolemia or red blood cell problems → hypoxia
• Risk of ineffective cerebral perfusion
  • If cause includes head/brain/nerve problems:
    • stroke, severe head injury, epilepsy, cranial surgery
• Electrolyte imbalance
  • If hyponatremia/hypernatremia/hypokalemia
• Risk of hypovolemia
  • In dehydration
• Acute confusion / anxiety
  • Related to disrupted thought processes

Step 3: Interventions (homework / standards reference)

• Homework instruction:
  • For each nursing diagnosis, open the Indonesian nursing intervention standards for delirium-related problems.
• The lecture states:
  • Nursing interventions are the same as the standards (per referenced documents).

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Speakers / sources featured

• Speaker: Mrs. Ayu (lecturer/teacher)
• Framework/source named:
  • Gordon’s functional health patterns (11 patterns referenced)
• Instruments/tools named:
  • Glasgow Coma Scale
  • Richmond Agitation-Sedation Scale (RAS; subtitle appears as “remont…scale ras ya”)
  • Delirium Screening Tool
  • Informal questionnaire on cognitive decline in the elderly
• No other clearly cited external authors/publications were identified in the subtitles beyond the “bibliography used.”