Mr. Jack Baroni, a seventy-two-year old male, was admitted to the skilled care f

Question

Mr. Jack Baroni, a seventy-two-year old male, was admitted to the skilled care facility for rehabilitation following an open reduction, internal fixation of the right hip. Mr. Baroni had fallen while going up the stairs of his home suffering an intertrochanteric, comminuted fracture of the right femur. He has no recollection of what caused him to fall. He is married and until his surgery was working part time as a school-crossing guard. While in the hospital, Mr. Baroni exhibited mental status changes including disorientation and confusion. His wife reports that he never had this problem previous to the surgery. He is continent of bowel and bladder. Mr. Baroni was in relatively good health until the fall. He and his wife agree that he should return home after rehabilitation is complete. The following questions relate to the above situation. 1. Identify specific assessments that would be required for Mr. Baroni because of his age and condition. 2. Describe possible reasons causing Mr. Baroni to fall. 3. Describe methods for assessing Mr. Baroni’s mental status. 4. Describe possible reasons for his altered mental status. 5. Write three individualized problems/nursing diagnosis and goals for Mr. Baroni. 6. List nursing actions related to altered mental status.

Explanation / Answer

1. Identify specific assessments that would be required for Mr. Baroni because of his age and condition.

There are quiet a few assessments and evaluation required for the patients inspite of his age and condition. Following are the initial to progressive assessments required for the patient,

Immediate evaluation by the nurse after a resident falls should include a review of the resident systems and description of injuries. Upon evaluation, the nurse should stabilize the resident and provide immediate treatment if necessary.

Evaluation of the resident's condition before, during or immediately after the fall provides clues to possible causes. Risk factors related to medical conditions or medication use may be reflected in abnormal values for any of the following:

• Vital signs (T, P, R, BP).

• Postural blood pressure and apical heart rate.

• Finger stick glucose (for diabetics).

When indicated by the resident's condition and history, laboratory tests such as CBC, urinalysis, pulse oximetry, electrolytes and EKG should be performed.

Residents should have increased monitoring for the first 72 hours after a fall. Each shift, the nurse should record in the medical record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. Reference to the fall should be clearly documented in the nurse's note.

Past history of a fall is the single best predictor of future falls. In fact, 30-40% of those residents who fall will do so again. Thus, it is crucial for staff to respond quickly and effectively after a fall. The Fall Response (Table 3) is a comprehensive approach that forms the backbone of the Falls Management Program (FMP). It includes the following eight steps:

I. Evaluate and monitor resident for 72 hours after the fall.

II. Investigate fall circumstances.

III. Record circumstances, resident outcome and staff response.

IV. FAX Alert to primary care provider.

V. Implement immediate intervention within first 24 hours.

VI. Complete falls assessment.

VII. Develop plan of care.

VIII. Monitor staff compliance and resident response.

The clues discovered during immediate resident evaluation and increased monitoring, the FMP Falls Assessment is used for a more in-depth look at fall risk.

The Tracking Record for Improving Patient Safety (TRIPS) is the method used in the FMP to report all types of falls. The Centers for Medicare and Medicaid Services' definition of a reportable fall includes the following:

• An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall.

• The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall.

• When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred.

• The distance to the next lower surface (in this case, the floor) is not a factor in determining whether a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall.

2. Describe possible reasons causing Mr. Baroni to fall.

Older patients are at high risk of developing delirium during hospitalization for a hip fracture, which is associated with worse outcomes,"

Five areas of risk accepted in the literature as being associated with falls are included. They are:

• Medications—antidepressants, antipsychotics, benzodiazepines, sedative/hypnotics and digoxin.

• Orthostatic hypotension.

• Poor vision.

• Impaired mobility.

• Unsafe behavior.

The resident's footwear and foot care as well as environmental and equipment safety concerns should also be assessed. In the FMP, these factors are part of the Living Space Inspection.

Evidence demonstrates patient variables that increase a patient’s risk for falling:

• Age (over age 65)

• Mentation

o Cognitive dysfunction, delirium, dementia

• Weak or Impaired mobility

• Assistance with toileting needs

• Medications

o Polypharmacy (4 or more drugs)

o Anticonvulsants, antipsychotics, benzodiazepines,

o antidepressants, Class IA antiarrythmics, opiates, sedatives,

o diuretics

• Physical hazards in room

o Poor lighting

o Lack of handrails in bathroom

o Poorly anchored rugs

o Clutter

3. Describe methods for assessing Mr. Baroni’s mental status.

Although AMS is common in presentation, its work-up is challenging because the potential causes are vast, and they vary from non-serious to life-threatening. Therefore, a thoughtful, comprehensive approach is essential, which

involves clarifying the history and onset of symptoms with the patients and/or carers, and localising specific signs or symptoms to narrow the differential.

Assessing a patient with AMS is difficult because obtaining a reliable history is often impossible. Initially, it is imperative to establish basic life support. Once the patient's airway, breathing, and circulation have been secured, a secondary emergency survey should be conducted. This includes securing adequate intravenous access, providing oxygen, and obtaining important vital signs (e.g., temperature, respiratory rate, heart rate, BP, oxygen saturation, and blood sugar). See Urgent considerations section for conditions requiring immediate management.

After emergency treatment and stabilisation of the patient, a directed differential diagnosis should be considered. Directing the differential may be even more problematic in older patients, who often present with relatively common conditions in uncommon, subtle manners. For example, they may present with infections without fever or leukocytosis, or a perforated viscus without abdominal pain or tenderness. It is therefore important to tailor a thoughtful approach specific to individual patients. The use of a logical and stepwise approach is preferred to one that relies on broad testing, which can predispose to iatrogenesis.

Physical examination:

A detailed head to toe physical examination will often yield clues as to the cause. Fully undress and examine the entire patient. Don’t leave a square inch unexamined (you’d be amazed where you’ll find a fentanyl patch sometimes). Pay particular attention to:

Glasgow Coma Scale

Eyes Verbal Motor

4 – Spont

3 – Loud voice

2 – To Pain

1- None 5 – Oriented

4 – Confused

3 – Inapprop words

2 – Incomprehensible

sounds

1 – No Sounds 6 – Obeys

5 – Localizes to pain

4 – Withdraws to pain

3 – Abnormal flexion

posturing

2 – Abnormal extension

posturing

1 – None

GCS score was designed to predict outcome after head trauma. Although we frequently use it to help decide who needs aggressive management (“less that eight, intubate!”), it has never been validated for that purpose. Further, there is often a 1-2 point disagreement between individual evaluators. It is, however, a quick useful way to communicate overall level of arousal.

• Vital signs

o Does the patient have a fever?

o Is the patient bradycardic or tacycardic?

o Is the patient bradypneic or tachypneic?

o Is the patient hypotensive or severely hypertensive?

• Neurologic status

o Level of alertness

o GCS score (see above) or AVPU scale (A=alert, V=responds to verbal stimuli, P=responds to painful stimuli, U=unresponsive). A verbal description is helpful

o How difficult is it to keep the patient awake?

• Content of thought and speech

o Does the patient stay focused?

o Is their speech tangential?

o Is the patient appropriately oriented?

o Does the patient keep asking the same questions over and over (perseveration)?

o Are they reacting to internal stimuli?

• Assess for focal motor findings

o Is there weakness or pronator drift?

o Cranial nerve examination (especially pupils)

o Remember, the brainstem is where isolated structural or ischemic lesions can cause decreased arousal. Decreased level of consciousness with cranial nerve findings is a brainstem lesion until proven otherwise.

o Evaluate for tremulousness or abnormal reflexes

o Common in withdrawal states or metabolic derangements

• Cardiovascular examination

o Are there arrhythmias (a-fib) that predispose to embolic strokes?

o Is there a murmur? endocarditis?

o Is there evidence of good peripheral circulation?

o Are there pulmonary findings that indicate pneumonia (sepsis) or pulmonary edema (hypoxia)?

o Are there bruits over the carotid arteries?

• Abdominal examination

o Is there ascites, caput medusa, liver enlargement or tenderness (hepatic encephalopathy)?

o Is the abdomen tender (appendicitis, intussusception, abdominal sepsis source, mesenteric ischemia)?

• Genitourinary and rectal examination

o Is the patient making urine (uremic encephalopathy)?

o Are there signs or urinary, vaginal, prostatic or perineal infection?

o Is there melena or blood in the stool?

• Skin, extremity, musculoskeletal examination

o Are there petechiae (meningococcemia)?

o Is there a dialysis graft (uremic encephalopathy)?

o Are there track marks from injection drug abuse?

o Are there transdermal drug patches?

o Is the skin jaundiced (hepatic encephalopathy)?

o Is there nuchal rigidity or meningismus (CNS infection)?

o Are there signs of trauma (raccoon’s eyes, Battle ‘s sign, hemotympanum)?

o Are there infectious sources noted (decubitus ulcers, cellulitis, abscesses)?

o Are there masses or lymphadenopathy that might indicate cancer (paraneoplastic syndromes)

History and physical examination findings are usually enough to help you categorize the change in mental status as delirium, dementia or psychosis. Further testing should be ordered as below to help narrow the differential within each of these categories of AMS.

Diagnostic testing:

Generally, diagnostic testing is used to rule in or rule out items on your differential diagnosis and should not be ordered in a “shot-gun” fashion. In the case of a patient with an undifferentiated AMS presentation, liberal use of diagnostic studies is frequently necessary because of the breadth of the differential and the high stakes involved in delaying appropriate treatment.

It is helpful to think of the main categories of causes for AMS and use diagnostic testing if any of these categories cannot be ruled out by H&P alone.

• Metabolic or Endocrine causes

o Rapid glucose

o Serum electrolytes (Na+, Ca+)

o ABG or VBG (with co-oxymetry for carboxy- or met-hemoglobinemia)

o BUN/Creatinine

o Thyroid function tests

o Ammonia level

o Serum cortisol level

o Toxic or medication causes

• Levels of medications (anticonvulsants, digoxin, theophylline, lithium, etc.)

o Drug screen (benzodiazepines, opioids, barbiturates, etc.)

o Alcohol level

o Serum osmolality (toxic alcohols)

o Infectious causes

• CBC with differential

• Urinalysis and culture

• Blood cultures

• Chest X-ray

• Lumbar puncture (with opening pressure)

• Always CT first if you suspect increased ICP.

• Traumatic causes

• Head CT/ cervical spine CT

• Neurologic causes

o Head CT (usually start without contrast for trauma or CVA)

o MRI (if brainstem/posterior fossa pathology suspected)

o EEG (if non-convulsive status epileptics suspected)

• Hemodynamic instability causes

o ECG

o Cardiac enzymes (silent MI)

o Echocardiogram

o Carotid/vertebral artery ultrasound.

4. Describe possible reasons for his altered mental status.

Head injuries (e.g., concussions, traumatic brain injuries) are common neurologic conditions that alter mental status. Hip tenderness might suggest occult hip fracture, a frequently missed trigger for delirium in frail older patients, particularly if they are bed-bound.

5. Write three individualized problems/nursing diagnosis and goals for Mr. Baroni.

6. List nursing actions related to altered mental status.

The following are the common goals and expected outcomes for Acute Confusion:

• Patient has diminished episodes of delirium.

• Patient regains normal reality orientation and level of consciousness.

• Patient verbalizes understanding of causative factors when known.

• Patient initiates lifestyle/behavior changes to prevent or minimize recurrence of the problem.

• Patient demonstrates appropriate motor behavior.

• Patient participates in activities of daily living (ADLs).

Nursing Assessment

The following are the comprehensive assessments for Acute Confusion:

Assessment Rationales

Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly patient), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors. Baseline information assists in developing a specific plan.

Conduct an accurate mental status examination that includes the following:

• Overall appearance, manner, and attitude

• Behavior observations and level of psychomotor behavior

• Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by patient)

• Insight and judgment

• Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)

• Attention Abnormal attention is a significant diagnostic characteristic of delirium. Delirium is a state of mind, while agitation is a behavioral manifestation. Some patients may be delirious without agitation and may actually have withdrawn behavior. This is a hypoactive form of delirium. Some patients have a mixed hypoactive/hyperactive type of delirium.

Assess patient’s behavior and cognition systematically and continually throughout the day and night as appropriate. Delirium always involves acute change in mental status; therefore knowledge of the patient’s baseline mental status is key in assessing delirium.

Evaluate and report possible physiological changes (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). Such changes may be contributing to confusion and must be corrected.

Closely monitor lab results. Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate). Once acute confusion has been recognized, it is necessary to identify and treat the associated underlying causes.

Review medication. Determine current medications/drug use—especially antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, opiates (associated with high risk of confusion)—and schedule of use as combinations increase risk of adverse reactions/interactions (e.g., cimetidine + antacid, digoxin + diuretics, antacid + propranolol).

Medication is one of the most critical modifiable factors that can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives.

Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response. This should be done to determine degree of impairment.

Note occurrence/timing of agitation, hallucinations, violent behaviors. Assess for sundown syndrome. This phenomenon associated with confusion occurs in the late afternoon. The patient exhibits increasing restlessness, agitation, and confusion. Sundowning may be a sign of sleep disorders, hunger, thirst, or unmet toileting needs.

Nursing Interventions

The following are the therapeutic nursing interventions for Acute Confusion:

Interventions Rationales

Aid with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, painmanagement).

Assisiting with treatment of underlying problem is important to maximize level of function and prevent further deterioration.

Orient patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures greater degree of safety for the patient.

Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli. Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient.

Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings). The confused patient may not completely understand what is happening. Presence of family and significant others may enhance the patient’s level of comfort.

Give simple directions. Allow sufficient time for patient to respond, to communicate, to make decisions. This communication method can reduce anxiety experienced in strange environment.

Avoid challenging illogical thinking. Challenges to the patient’s thinking can be perceived as threatening and result in a defensive reaction.

Provide for safety needs (e.g., supervision, siderails, seizureprecautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices). This is to prevent untoward incidents and to promote safety.

Avoid/limit the use of restraints. This may worsen the situation and increase likelihood of untoward complications.

Maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucoselevels, blood pressure.

To treat underlying causes of delirium in collaboration with the health care team.

Communicate patient’s status, cognition, and behavioral manifestations to all necessary providers. Recognize that patient’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as patient preference for caregivers.

Plan care that allows for appropriate sleep-wake cycle. Disturbance in normal sleep and activity patterns should be minimized as those patients with nocturnal exacerbations endure more complications from delirium.

Tell patient to decrease caffeine intake. Decreasing caffeine intake helps to reduce agitation and restlessness.

Manipulate the situation to make it as close to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight. An atmosphere that is close to the patient provides orienting clues, maintains an appropriate balance of sensory stimulation, and secures safety.

Identify self by name at each contact; call the patient by his or her preferred name. Appropriate communication techniques for patients at risk for confusion.

Offer reassurance to the patient and use therapeutic communication at frequent intervals. Patient reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety.

Identify, evaluate, and treat pain immediately.

Unmanaged pain is a potential cause for delirium.

Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes). Continuity of care helps decrease the disorienting effects of hospitalization.

Maintain patient’s sleep-wake cycle as normal as possible (e.g., avoid letting the patient take daytime naps, avoid waking patients at night, give sedatives but not diuretics at bedtime, provide pain relief and backrubs).

Acute confusion is accompanied by disruption of the sleep-wake cycle.

Assist the family and significant others in developing coping strategies. The family needs to let the patient do all that he or she is able to do to maximize the patient’s level of functioning and quality of life.

Teach family to recognize signs of early confusion and seek medical help. Early intervention prevents long-term complications.

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