Critical Care Connection
Preventing Delirium in Postoperative Patients

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Delirium

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines delirium as an acute and fluctuating brain organ dysfunction presenting with a disturbance of consciousness with reduced ability to focus, sustain, or shift attention.8 Delirium is a change in cognition that is not accounted for by a previously diagnosed condition such as dementia. This change in cognition or perceptual disturbance develops over a short period of time (hours to days) and may fluctuate over the

Which Patients Are at Risk for Postoperative Delirium?

Although any patient is at risk of developing postoperative delirium, certain factors place the patient at increased risk. These risk factors include: advanced age (risk increases with age), alcohol use, smoking history, chronic disease states, underlying cognitive disorder (eg, dementia), pulmonary disease, history of depression, polypharmacy, medications (anticholinergics, benzodiazepines, and central nervous system depressant agents), electrolyte imbalances, hyper/hypoglycemia, acid-base

Assessing Postoperative Delirium

Diagnosis of delirium in the critically ill postoperative patient can be challenging because of the subtle and fluctuating nature of the cognitive dysfunction. Current practice standards endorse the use of valid and reliable tools developed to more objectively identify patients with delirium. Delirium assessment tools should be used frequently and consistently to allow for early identification of the syndrome and appropriate treatment interventions. The two most widely used and adopted delirium

Pain Management

Managing pain is a priority for perianesthesia nurses. Ensuring effective pain management, especially in the first 48 hours postoperatively, has been found to significantly reduce the incidence of postoperative delirium.6 Current guidelines advocate for treatment of pain to include preemptive analgesia before procedures and/or interventions expected to cause discomfort.12 Although opiate agents increase the risk of postoperative delirium, untreated pain is also a known risk factor for cognitive

Orientation

Providing ongoing reorientation to the patient at risk of postoperative delirium is an important and easy step for the nurse to implement. Ongoing orientation encompasses maximizing social interaction and family visitation for the patient as soon as possible after the procedure.2, 3 Other strategies include the presence of calendars, clocks, newspapers, and other time-oriented references. During daytime hours, have the lights on and dim or turn off lights during evening/night hours to replicate

Sleep Hygiene

Promoting sleep and re-establishing normal sleep patterns for the patient while hospitalized is an important intervention in both the prevention and treatment of delirium.9, 12 Sleep also restores the body's immune protection, improves metabolism, and reduces pain.16 Sleep hygiene protocols strive to restore the patient's normal sleep cycle by encouraging daytime and nighttime routines within the care structure and functions of a busy nursing unit. Normal sleep cycles are typically 90 minutes;

Early Mobility

Several studies have found that promotion of patient mobility is an effective intervention in reducing and treating delirium.12, 17 Mobility re-establishes both a physical and cognitive function for the patient. Early mobility protocols for critically ill patients encourage gradual and progressive mobility that begins with passive range of motion from moving to sitting at the edge of the bed to full mobilization. For the perianesthesia practice environment, encouraging patient mobility as much

Summary

Perianesthesia nurses are vital in the effort to recognize risk factors that may increase a patient's risk of developing postoperative delirium. Early recognition of patients who have acute cognitive dysfunction and implementation of strategies to prevent or minimize this complication are needed to reduce the adverse outcomes associated with postoperative delirium.

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is a Research Nurse Scientist, Critical Care, University of Colorado Hospital, and an Associate Professor, University of Colorado College of Nursing, Aurora, CO

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There are more references available in the full text version of this article.

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is a Research Nurse Scientist, Critical Care, University of Colorado Hospital, and an Associate Professor, University of Colorado College of Nursing, Aurora, CO

Conflict of interest: None to report.

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