1. Delirium Assessment and Management Presented by: Jonna Bobeck BSN, RN, CEN

2. Introduction Acute change in consciousness Hyperactive delirium Hypoactive delirium Associated with increased length of stay Often goes undetected

3. Supporting Evidence Need for standardized assessment tools Tools ◦ Confusion Assessment Method (CAM-ICU) ◦ Intensive Care Delirium Screening Checklist (ICDSC) Also implementing the ABCDE bundle ◦ A - awakening ◦ B - breathing ◦ C- coordination ◦ C- choice ◦ D - delirium

4. Supporting Evidence Understudied and underreported Pre-existing dementia, hypertension, alcoholism, and severity of illness Recent studies conclude early mobility improves cognitive function Decrease sedative use and modify iatrogenic risk factors

5. Managing ICU Delirium The FDA has not approved a drug to treat delirium FDA has issued an alert regarding antipsychotic medication All patients receiving antipsychotic medications should be closely monitored

6. Managing ICU Delirium Use the THINK mnemonic ◦ T- toxic situations ◦ H – hypoxemia ◦ I – infection/sepsis ◦ I – immobilization ◦ K – electrolyte abnormalities

7. Delirium Screening Patients admitted to Intermediate or Advanced ICU with be screened for delirium on admission and at least every 12 hours thereafter

8. Process for Utilization Add the Delirium Screening to interventions Complete the screening Implement the ABCDE bundle

9. Process for Utilization: Patient Positive for Delirium Orientation Environment Clinical paramaters

10. Process for Utilization: Patient Positive for Delirium Pharmacologic ◦ Use THINK mnemonic ◦ T – toxic situations ◦ H – hypoxemia ◦ I – infection/sepsis ◦ N – non-phamrocologic interventions ◦ K – postassium or electrolyte problem

11. Early Mobilization Patients will be progressively ambulated and mobilized Objective assessment every 12 hours

12. Process for Utilization Step 1: baseline mobility ◦ Passive ROM twice a day ◦ Turn every 2 hours ◦ Increase sensory stimulation during day ◦ Allow rest at night ◦ Involve families

13. Process for Utilization Assess mobility progression criteria ◦ Responds to verbal stimuli with eye opening ◦ Oxygen demands are stable ◦ No unstable fractures ◦ No increased titration of vasopressors for 12 hours

14. Process for Utilization: Progressive Mobilization Step 2: bed to chair position Step 3: life to chair Step 4: dangle on edge of bed Step 5: transfer to chair Step 6: standing at bedside Step 7: ambulate at bedside

15. Process for Utilization Assess tolerance of activity by: ◦ Unexpected change in vs ◦ Symptomatic decrease in SBP ◦ Decrease in Scvo2 ◦ Increase in FiO2 ◦ Desaturation less than 90% ◦ Ventilator dysyncrony ◦ Sustained increase in secretions

16. Key Points O2 may not be increased during mobilization Notify provider if FiO2 does not return to baseline RT may adjust ventilator to support increased requirements Advance only 1 step per day

17. Summary: Putting it all Together ABCDE bundle

18. References Pullman Regional Hospital,(2012). Delirium screening protocol Retrieved from \\prhs5\groups\Policies and Procedures\Patient Care Pullman Regional Hospital, (2012). Early mobilization of ventilator patients protocol Retrieved from \\prhs5\groups\Policies and Procedures\Patient Care