Video Case Study - Delirium

Nurse Melinda works on a medical surgical unit and is caring for Kadija, a 72-year-old with a history of heart failure who was admitted for pyelonephritis.

After settling Kadija in her room, Nurse Melinda goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Kadija’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Melinda recognizes important cues, including Kadija’s vital signs, which are temperature of 102.2 F or 39 C, heart rate 102 beats per minute, respirations 19 breaths per minute, and blood pressure 140/80 mmHg.

Nurse Melinda notices Kadija appears anxious, and her eyes are moving back and forth across the room. She gathers additional information from Kadija.

Nurse Melinda: Hi Kadija, how are you feeling today? Kadija: Don’t you see that?

There are a bunch of spiders on the wall behind you. Nurse Melinda turns around and notes there is nothing on the wall.

Nurse Melinda: I don’t see any spiders, but I understand that must be very scary for you. You're safe here with me.

Nurse Melinda conducts a brief cognitive screening and determines that Kadija is oriented to self, but not time, place, or situation.

Next, Nurse Melinda analyzes these cues. She reviews the electronic health record, or EHR, and notes that Kadija has no history of psychiatric illness.

Nurse Melinda recognizes that underlying factors, such as infection, fever, pain, sleep deprivation, fluid and electrolyte imbalance, as well as certain medications, can lead to alterations in a patient’s mental status, causing problems like delirium, especially in patients with advanced age and preexisting medical conditions.

She also recalls that delirium can develop over several hours or days and can result in a waxing and waning of mental function, including memory, thinking, language, behavior, mood, and personality.

Hallucinations and delusions also often occur. Nurse Melinda realizes that Kadija needs management of her altered mental status.

Now, using the information she's gathered, along with Kadija's medical history, Nurse Melinda chooses a priority hypothesis of disturbed thought processes.

Then, she generates solutions to address Kadija’s altered mental status that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Kadija will be free from injury during the shift.

Nurse Melinda then takes action to implement these solutions. She contacts that health care provider who comes to the bedside and assesses Kadija.

The health care provider tells Nurse Melinda that they’ve ordered an antibiotic for Kadija, and an antipyretic, to help address the underlying cause of her delirium.

Then, nurse Melinda calls Kadija’s son to update him on the plan of care and then gathers supplies and re-enters Kadija’s room.

Nurse Melinda: Hi Kadija, my name is Nurse Melinda. You’re in the hospital and today is March 6th, 2023.

I have some medicine to help with your kidney infection, and some pills to help reduce your fever. Kadija: Hospital?

I’m not going to the hospital. I must kill the spiders in my house.

Nurse Melinda: I understand, but right now, you’re in the hospital with me and I’m your nurse. You’re safe here and I don’t see any spiders.

Nurse Melinda administers both medications according to the principles of safe medication administration. Nurse Melinda: I spoke with your son and he’s on his way to the hospital.

I’m going to stay with you until he arrives. Kadija: My son is coming?

He’s already here in his room down the hall. Nurse Melinda sits with Kadija, updates the date on Kadija’s whiteboard and moves the clock to her bedside table to promote orientation.

She then ensures that fall precautions are in place by putting Kadija’s bed in the lowest locked position, ensuring the bed alarm is on, and putting a fall alert sticker outside her door.

At the end of the shift, Nurse Melinda evaluates the outcome of her actions. She takes Kadija’s vital signs, which are temperature 100.4 F.

of 38 C. heart rate 90 beats per minute, respirations 17 breaths per minute, and blood pressure 136/82 mmHg.

Kadija’s son is at the bedside, showing Kadija pictures of her family that he brought in from home. Although Kadija remains disoriented to time, place, and situation, she’s sitting comfortably in bed and no longer reports seeing spiders.

Alright, as a quick recap... Nurse Melinda recognized and analyzed cues related to Kadija’s delirium and prioritized hypotheses and generated solutions to address this problem.

Nurse Melinda then took action and implemented pharmacologic and nonpharmacologic measures to address Kadija’s delirium and evaluated Kadija’s outcomes and compared them to the expected outcome.

Since Kadija remained safe during the shift, Nurse Melinda determined the plan of care was successful.