Special observation and older persons with dementia/delirium: a disappointing literature review

Background. In gerontological practice, special observation is a known nursing activity across different settings. The group that possibly are most effected by this intervention are older persons with dementia and/or delirium. The research literature about special observations in the mental health field is small, more disappointingly there appears to be little published literature about special observations in regard to older persons with dementia and/or delirium. Aims. The aims of this study are to (i) establish the state of current published research on special observations in regard to older persons with dementia and/or delirium and (ii) make recommendations for research and practice. Design and method. A literature review. Results. Most literature pertains to adult mental health practice and services. Themes were generated and discussed in relation to gerontological practice. Conclusion. This review has established there is variance in the usage of the terms ‘special observation’ and ‘constant observation’. It concludes that there is no published research on special or constant observations in relation to older people with dementia/delirium or the purpose of this activity. There is therefore a clear need to establish a research base in the topic. Implications for practice. Given the limited evidence, practitioners and managers need to be cautious when writing and implementing policies about special observation. However, until gerontological research is improved, research from mental health nursing will need to be drawn on with caution and the purpose of special observation determined locally. To be of therapeutic value and to be cost effective, special observation should be seen as a skilled nursing intervention and not a passive ‘watching’ or ‘sitter’ activity.     

State of the science in pediatric ICU delirium: An integrative review

Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.     

Long term outcome after delirium in the intensive care unit

Aims and objectives. This research studied the long term outcome of intensive care delirium defined as mortality and quality of life at three and six months after discharge of the intensive care unit. Background. Delirium in the intensive care unit is known to result in worse outcomes. Cognitive impairment, a longer stay in the hospital or in the intensive care unit and a raised mortality have been reported. Design. A prospective cohort study. Methods. A population of 105 consecutive patients was included during the stay at the intensive care unit in July–August 2006. The population was assessed once a day for delirium using the NEECHAM Confusion Scale and the CAM‐ICU. Patients were visited at home by a nurse researcher to assess the quality of life using the Medical Outcomes Study Short‐Form General Health Survey at three and six months after discharge of the intensive care unit. Delirious and non delirious patients were compared for mortality and quality of life. Results. Compared to the non delirious patients, more delirious patients died. The total study population discharged from the intensive care unit, scored lower for quality of life in all domains compared to the reference population. The domains showed lower results for the delirious patients compared to the non delirious patients. Conclusions. Mortality was higher in delirious patients. All patients showed lower values for the quality of life at three months. The delirious patients showed lower results than the non delirious patients. Relevance to clinical practice. Nurses are the first caregivers to observe patients. The fluctuating delirious process is often not noticed. Long term effects are not visible to the interdisciplinary team in the hospital. This paper would like to raise the awareness of professionals for long term outcomes for patients having experienced delirium in the intensive care unit.     

Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review

Aim. To review research on early oral feeding following elective, open colorectal surgery. Background. Fasting following gastrointestinal surgery is a traditional surgical practice, based on fears of causing postoperative complications if oral intake begins before bowel function returns, but fasting following elective surgery is questionable as a best practice. Methods. Searches in Journals@Ovid CINAHL, MEDLINE, PubMed, Web of Science and The Cochrane Library for primary studies, published during 1995–2004, used the keywords: ‘surgery’, ‘postoperative’, ‘elective, ‘colorectal’, ‘bowel, ‘colon’, ‘oral’, ‘enteral’, ‘feeding’, ‘early’, ‘traditional’. Studies of adults undergoing elective, open colorectal surgery who were allowed fluids and food before bowel function returned (early feeding) were included. Outcomes of interest were safety, tolerability, duration of gastrointestinal ileus and length of hospital stay. Critical appraisal of randomized and controlled studies was undertaken following inclusion. Results. Fifteen studies comprising 1352 patients were reviewed. All studies concluded early feeding was safe, based on complications rates. Total complications were 12·5% (range 0–25%) for 935 early feeding patients, with no increased risk of anastomotic leak, aspiration pneumonia, or bowel obstruction. For all studies an average of 86% patients (range 73–100%) tolerated early feeding. Studies demonstrating faster resolution of postoperative ileus or shorter hospitalization were associated with multimodal perioperative care, including early mobilization, epidural analgesia and comprehensive patient education. Appraisal of five randomized trials revealed no blinding and inadequate randomization. Conclusions. This review supports early oral feeding after elective, open colorectal surgery and challenges the traditional practice of fasting patients until return of bowel function. Early feeding was safe, well‐tolerated and easy to implement. Reduced length of ileus and shorter hospitalization may occur with multimodal protocols. Relevance to clinical practice. Nurses can highlight this new evidence for other health professionals, advocate development of clinical protocols featuring early feeding and participate in multi‐disciplinary, multi‐method research regarding benefits of early feeding.     

基于强化健康教育的早期活动干预在预防呼吸科机械通气患者谵妄中的应用

目的探讨基于健康教育的早期活动干预在预防呼吸内科机械通气患者谵妄中的应用效果。方法选取2015年4月至2016年2月收治呼吸内科机械通气患者184例,采用数字表法分为试验组和对照组各92例。对照组患者实施呼吸内科机械通气常规护理措施,试验组患者在对照组的基础上实施强化健康教育的早期活动干预,包括成立干预小组、实施护理干预。研究结束后,比较两组患者谵妄发生情况、机械通气时间、住院时间及满意度。结果与对照组患者比较,试验组患者谵妄发生率明显降低,谵妄状态持续时间、机械通气时间、住院时间均明显缩短(P0.05);试验组患者护理满意度高于对照组(P0.05)。结论基于强化健康教育的早期活动干预可有效降低呼吸内科机械通气患者谵妄发生率,改善患者谵妄持续状态,缩短住院时间,有利于提高患者对护理工作的满意度,值得临床推广。     

Sepsis associated delirium mimicking postoperative delirium as the initial presenting symptom of urosepsis in a patient who underwent nephrolithotomy

We report a case of 70 years old male who underwent percutaneous nephrolithotomy for renal calculi. After an uneventful recovery from anaesthesia, the patient developed delirium which manifested as restlessness, agitation, irritability and combative behavior. All other clinical parameters including arterial blood gas, chest X-ray and core temperature were normal and the patient remained haemodynamically stable. But 45 min later the patient developed florid manifestations of septic shock. He was aggressively managed in a protocolized manner as per the Surviving Sepsis Guidelines in the Critical Care Unit and recovered completely. There are no case reports showing postoperative delirium as the only initial presentation of severe sepsis, with other clinical parameters remaining normal. Both urosepsis and sepsis associated delirium have very high mortality. High index of suspicion and a protocolized approach in the management of sepsis can save lives.     

Deciphering the 4 D's: cognitive decline, delirium, depression and dementia--a review

PURPOSE: The purpose of this paper is to assist advanced practice nurses to recognize, identify, and diagnose cognitive change in older adults. BACKGROUND/RATIONALE: Optimal cognitive function is important for continued independence, and yet changes in cognition are frequently unrecognized among older adults. Cognitive change in older adults can be observed due to age-related cognitive decline, the development of acute confusion (delirium), depression, dementia and/or a combination of these. When the aetiological source for alterations in cognitive function is delirium or depression, the potential for reversibility mandates that the reason for the cognitive change be identified with steps taken to remedy the situation. Also, early recognition of dementia is an important factor in obtaining timely and appropriate care. These conditions can exist concurrently and may fluctuate making deciphering the reason for the cognitive change problematic. CONCLUSIONS: It is essential to understand how the 4 'D's' are expressed and to recognize the potential contributing factors to an observable change in cognitive function for diagnosis and treatment. Recommendations for obtaining a person's history are included.