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Delirium är ett akut förvirringstillstånd vanligt förekommande inom intensivvård och beräknas drabba upp till 80 % av patienter som vårdas på en intensivvårdsavdelning. Det kan yttra sig som osammanhängande tankemönster, slutenhet, agitation och ouppmärksamhet. Predisponerande faktorer i kombination med vissa utlösande faktorer kan leda till utveckling av tillståndet, men miljömässiga faktorer tros också påverka. Delirium bidrar till ökat lidande med såväl emotionell som fysiskt ökad stress, längre vårdtider och därmed ökade vårdkostnader. Behandlingsalternativen för tillståndet är många och kräver ett multifaktoriellt och multidisciplinärt omhändertagande för att kunna upptäckas, förebyggas och lindras. Eftersom intensivvårdssjuksköterskan ansvarar för omvårdnaden och dessutom har ett stort inflytande över den medicinska vården som bedrivs, syftar studien till att beskriva intensivvårdssjuksköterskans strategier i vårdandet av den deliriösa intensivvårdspatienten. Studien genomfördes med kvalitativ ansats och med fokusgruppsintervjuer som datainsamlingsmetod. Tre (n=3) fokusgruppsintervjuer genomfördes med totalt fjorton (n=14) intensivvårdssjuksköterskor. Data analyserades genom kvalitativ innehållsanalys och induktiv slutledning vilket genererade fyra (n=4) kategorier och elva (n=11) subkategorier. Resultatet presenterades genom följande kategorier: Skapa förutsättning för vila och återhämtning, Förankra till verkligheten, Arbeta enhetligt och målmedvetet och Sträva efter ett vårdande förhållningssätt. Strategierna, som grundade sig i olika vårdhandlingar, kunde ha flera betydelser i vårdandet av den deliriösa patienten. Strategierna som ansågs ha positiva effekter hos den deliriösa patienten, kunde också innebära svårigheter på grund av tillståndets komplexitet. En utmaning låg i att dessa patienter upplevdes vara både tålamods- och resurskrävande, något som kunde begränsa ett optimalt omhändertagande. Genom att bejaka ovanstående strategier och genom att uppmärksamma de svårigheter som sjuksköterskan upplever skulle vården av den deliriösa intensivvårdspatienten kunna förbättras och effektiviseras för att på så sätt skapa en tillvaro med mindre lidande för patienten.

In the present study the cognitive outcomes of cardiac surgery were examined in patients who did or did not develop delirium early post-operatively. The study expanded on previous research by investigating: (1) the relationship between delirium and functioning on specific cognitive domains; (2) the relationship between delirium and cognitive functioning after taking into account pre-existing cognitive impairment; and (3) the cognitive profile of delirium. The study employed a non-equivalent pre-test post-test design. Participants were 80 candidates for coronary artery graft replacement and/or heart valve repair or replacement operations who were 60 years of age or over. Participants underwent a neuropsychological assessment pre-operatively, daily assessments between post-operative days 2-5 for identification of delirium, and a follow-up neuropsychological assessment 12 weeks post-operation. Twenty-one participants met DSM-IV diagnostic criteria for delirium early post-operation. Participants who experienced delirium performed worse than participants who did not on one global cognitive measure and one specific cognitive domain at follow-up. However, this was likely due to the contribution of other factors such as age, years of schooling, pre-operative performance, and neurological events post-operation. There was no difference in the proportion of participants who did or did not develop delirium who met specified criteria for cognitive decline from pre-operation to follow-up. Significantly more participants who developed delirium, relative to those who did not, met criteria for pre-existing cognitive impairment. After taking into account pre-existing impairment and other potentially contributing variables, delirium was a significant predictor of performance on an attentional task at follow-up. There were no significant differences between the cognitive profiles of participants who did or did not develop delirium, at pre-operation or at follow-up. At both time points the profiles of these groups resembled the profile of a group of patients with vascular dementia. In conclusion, although participants who experienced delirium performed worse on certain cognitive domains, this appeared to be due to factors other than delirium. However, after taking pre-existing cognitive impairment, and other relevant variables into account, delirium adversely affected attentional performance. Delirium was associated with a vascular dementia profile, but this profile was not specific to delirium. Study findings have both theoretical and clinical implications. Consistent with the theoretical literature, the findings support impaired brain reserve as a risk factor for delirium, and the hypotheses that a combination of impaired brain reserve and events associated with delirium are responsible for subsequent cognitive performance. However, in the case of attention, events associated with delirium appear to be responsible for poorer performance, possibly due to the persistence of impaired attention, which is an essential feature of the delirium episode. A further theoretical implication is that individuals who experience delirium may be particularly vulnerable to developing vascular dementia, however, there needs to be further investigation of this risk in a non-cardiac surgery population. Clinically, study findings highlight the need to investigate possible cognitive impairment in individuals with cardiovascular disease, and in persons who experience delirium. When indicated, appropriate monitoring and/or treatment strategies should be employed to reduce the impact of cognitive deterioration.

ABSTRACT Aim. To describe intensive care nurses´ experiences of caring for patients with postoperative delirium after heart surgery. Background. Delirium is a common condition after heart surgery. Previous research has focused more on pathophysiology, incidence, etiology, prevention, detection and management, and less on how nurses caring for patients with delirium experience it. Design. A qualitative interview study. Method. Six intensive care nurses in a cardiothoracic intensive care unit were interviewed using a semi structured interview guide. Interviews where analyzed using qualitative content analysis. Results. The analyzed data resulted in a theme: desire to give good caring to patients with delirium, and three main categories: detecting delirium, caring for patients with delirium, willingness to improve care of patients with delirium. These main categories consisted of nine subcategories. Conclusion. Intensive care nurses´ goal is to provide good care even though the patient category is demanding. Despite increased awareness and transparency in the field of delirium care, it is important to highlight and address the emotions that arise as well as continuing with educational support to improve caring. Relevance to clinical practice. The intensive care nurse plays a key role in detecting, attending to and preventing postoperative delirium during patient care. The study highlights and confirms delirium as a challenge for nurses. The result can be used to raise awareness of the difficulties involved in nursing and highlight the need for improved knowledge and education in this area in order to improve nursing work environments. / ABSTRAKT Syfte. Beskriva intensivvårdssjuksköterskors erfarenheter av att vårda patienter med postoperativt delirium efter hjärtkirurgi. Bakgrund. Delirium är ett vanligt förekommande tillstånd efter hjärtkirurgi. Tidigare forskning har fokuserat mer på patofysiologi, incidens, etiologi, sätt att förebygga, upptäcka och behandla, men mindre på sjuksköterskors upplevelser av att vårda patienter med delirium. Design. En kvalitativ intervjustudie. Metod. Sex intensivvårdssjuksköterskor på en thoraxkirurgisk intensivvårdsavdelning intervjuades efter en semistrukturerad intervjuguide. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat. Det analyserade materialet resulterade i ett tema: strävan efter en god omvårdnad för patienter med delirium, och tre huvudkategorier: att upptäcka delirium, att vårda patienter med delirium, att vilja förbättra för patienter med delirium. Dessa huvudkategorier bestod i sin tur av nio underkategorier. Konklusion. Intensivvårdssjuksköterskor strävar efter att ge en god omvårdnad även om det är en svår patientkategori att vårda. Det är viktigt att synliggöra de känslor som omvårdanden väcker och trots att medvetenheten ökat och problemen synliggjorts så finns fortfarande ett behov och en önskan om mer utbildning för att förbättra omvårdnaden. Klinisk betydelse. Intensivvårdssjuksköterskor spelar en viktig roll i att upptäcka, vårda och förebygga postoperativt delirium och är den som arbetar närmast patienten. Studien belyser och bekräftar att patienter med delirium är en utmaning för sjuksköterskor. Resultatet kan användas för att medvetandegöra de svårigheter som finns i omvårdnaden och synliggör behovet av mer utbildning och kunskap med syfte att förbättra sjuksköterskornas arbetssituation.

BACKGROUND: Delirium is a disorder that is characterized by an acute change in cognitive functioning including inattention, and disordered thinking. Delirium disproportionately affects the population over the age of 65, and is associated with increased costs, worse outcomes and longer lengths of stay. Although delirium is estimated to affect approximately 10% of elderly patients in the emergency department (ED) and 42% of elderly inpatients, it often goes unrecognized by the clinical staff. There is evidence that delirium can be prevented through non-pharmacologic prevention strategies, however it is less clear which patients should be targeted for these measures. OBJECTIVES: The objective of this study is to identify risk factors for development of hospital-acquired delirium during the most proximal aspect of a patient’s hospital course, namely the ED. Secondary objectives of this study are to analyze resource utilization and outcomes associated with the development of hospital-acquired delirium. METHODS: This study is a secondary analysis of a prospective observational study conducted over 3 years at a single urban university hospital. Patients over the age of 65, who could complete a structured cognitive assessment interview, were screened for delirium by a trained research assistant. Patients that were judged to be not delirious in the ED, and who were then admitted to an inpatient unit were included in the final cohort. A validated chart review method was used to determine if patients developed delirium during the course of their hospitalization. Potential predictors of hospital-acquired delirium, including demographics, laboratory values, comorbidities and outcomes, were also abstracted from the medical chart. We performed a univariate analysis of these predictors and included those covariates with a p values ≤0.2 in multivariate analysis. We allowed 1 predictor per 10 outcomes in the final model to avoid over-fitting and evaluated the discriminatory ability and calibration of the model using the c-statistic and Hosmer-Lemeshow goodness-of-fit test. RESULTS: Of the 520 patients included in our cohort, 77 developed delirium over the course of their inpatient visit. Multivariate analysis identified 7 risk factors to predict delirium in elderly emergency department patients admitted to the hospital. Patients were more likely to develop delirium during their stay if they were age 80 or older, had a history of dementia, had a history of stroke or transient ischemic attack, were hypoxic or hyponatremic in the ED, or had an ED admitting diagnosis of acute stroke/transient ischemic attack or fall. The model had a c-statistic of 0.73 and a non-significant p-value of 0.7 in the Hosmer-Lemeshow goodness-of-fit test. CONCLUSION: The predictive model that we created may help identify a population to target for delirium prevention strategies in elderly emergency department patients, thereby reducing delirium incidence in hospitalized patients, and the associated morbidity, mortality, and healthcare utilization.

Background: Delirium superimposed on dementia (DSD) is a highly prevalent, yet difficult to recognize problem in hospitals. Delirium is a disturbance in cognition often seen in persons aged 65 and older. DSD occurs when a person living with dementia (PLWD) also develops delirium. DSD is a highly distressing experience for caregivers. Aims: This study aims to explore the experiences of caregivers of older persons with DSD in acute care hospitals; their role in the detection and management of DSD; and the type of support they require during this experience. The knowledge generated from this study can be used to identify strategies to assist caregivers during their experience, and to improve the early detection and management of DSD, with the aim to improve health outcomes for both the hospitalized older person with DSD and the caregiver. Methods: Thorne’s interpretive description method was used. In-person, semi-structured interviews were conducted with nine caregivers of older persons with DSD who were hospitalized in four medicine units. Interviews were transcribed and thematic analysis was conducted. Results: The following themes related to caregivers’ experiences were identified: (a) caregivers found DSD to be an overwhelming experience, (b) caregivers were concerned about the quality of care that the older person received, (c) caregivers’ experiences were influenced by the nature of their relationship with the health care team, and (d) caregivers can play an important role in the detection and management of DSD. Conclusion: Findings provide guidance in increasing support and building collaborative relationships between caregivers and the health care team. Recommendations on delivering caregiver-centred care to caregivers of older persons with DSD are outlined. / Thesis / Master of Science in Nursing (MSN)

SAMMANFATTNING Syftet med studien var att studera hur sjuksköterskan inom intensivvård använder NuDesc(The Nursing Delirium Screening Scale) och om de anser sig ha tillräcklig kunskap för attbedöma delirium med hjälp av NuDesc. Studien är en kvantitativ tvärsnittsstudie med datainsamling via en enkät som konstrueratsspeciellt för denna studie. Enkäten besvarades av 15 intensivvårdssjuksköterskor på ettuniversitetssjukhus i Mellansverige. Resultatet visade att bedöma delirium på en intensivvårdsavdelning uppfattas avrespondenterna som ganska svårt även om de tycker sig ha tillräckligt med kompetens attanvända bedömningsinstrument NuDesc. Den psykomotoriska förlångsamningen tillsammansmed hallucinationer/ illusioner uppfattas av sjuksköterskorna som svårast att bedöma. / ABSTRACT The aim of the study was to examine how the nurse in intensive care use NuDesc (TheNursing Delirium Screening Scale) and if they feel they have sufficient knowledge to assessdelirium using NuDesc. The study is a quantitative cross-sectional study with data collection through a questionnairedesigned specifically for this study. The survey was answered by 15 ICU nurses at auniversity hospital in central Sweden. The results showed that to assess delirium in intensive care was perceived by respondents tobe quite difficult even if they think they have enough skills to use the assessment instrumentNuDesc. Psychomotor retardation with illusions/ hallucinations are perceived by nurses as themost difficult to assess.

No description available.

Background. Patients, who are receiving life-threatening treatment at the intensive care unit (ICU), often suffer from failure in their vital organs. Supporting treatement of their organs is a important part of the work in the ICU.  An overlooked complication in these patients is cognitive failure due to critical illness, also known as ICU-delirium. Research studies show that patients with ICU-delirium have increased care time and increased mortality. Aims The aim of this study was to describe the intensive care nurse's perception of and how ICU-delirium is assessed. The aim was also to compare how often assessment of ICU-delirium occurs with the frequency of assessment of sedation depth. Results 45 intensive care nurses responded that ICU delirium requires active measures from healthcare professionals. 43 considered that ICU delirium is a common response to the environment in an intensive care unit. Some (n= 40) indicated that their department has a routine regarding sedation, but 21 states that the protocol does not specify how often ICU delirium is to be assessed. The most common method for assessing ICU delirium was to see if the patient can follow instructions (n= 19) and if the patient has an outgoing behavior (n = 10). 42 indicated that ICU delirium is an under-diagnosed problem and 40 that it is a challenge to assess the patient. The study showed a significant difference (p = .0001) between how often intensive care nurses assess sedation depth and how often ICU delirium is assessed. Conclusions. The conclusion is that sedation assessment is performed more often than assessment of ICU-delirium. More education in the subject and more in-depth research is recommended. / Bakgrund. Patienter som vårdas inom intensivvården har ofta drabbats av kritisk sjukdom med svikt i vitala organ som följd. Understödjande behandling av dessa organ är en viktig del i arbetet inom intensivvården. En förbisedd komplikation hos patienten är sviktande kognitiva funktioner på grund av kritisk sjukdom, även benämnt intensivvårdsdelirium (IVA-delirium). Patienter med IVA-delirium har tidigare forskning visat ge längre vårdtider och ökad mortalitet. Syfte  Syftet med studien var att beskriva intensivvårdssjuksköterskans uppfattning om och hur IVA-delirium bedöms. Syftet var också att jämföra hur ofta bedömning av IVAdelirium sker med hur ofta bedömning av sederingsdjup sker. Metod En beskrivande och jämförande studie med kvantitativ ansats. Enkäter (n=112) delades ut till intensivvårdssjuksköterskor där 45 besvarades.  Huvudresultat 45 intensivvårdssjuksköterskor svarade att IVA-delirium kräver aktiva åtgärder från vårdpersonalen. 43 ansåg att IVA-delirium är en vanlig respons på miljön vid en intensivvårdsavdelning. En del (n=40) angav att deras avdelning har en rutin angående sedering men 21 uppger att protokollet inte anger hur ofta IVA-delirium ska bedömas. Den vanligaste metoden för att bedöma IVA-delirium var att se om patienten kan följa instruktioner (n=19) och om patienten har ett utåtagerande beteende (n=10). 42 angav att IVA-delirium är ett underdiagnosticerat problem och 40 angav att det är en utmaning att bedöma hos patienten. Studien visade en signifikant skillnad (p=.0001) mellan hur ofta intensivvårdssjuksköterskor bedömer sederingsdjup och hur ofta IVA-delirium bedöms.  Slutsatser Slutsatsen är att bedömning av sedering utförs oftare än bedömning av IVA-delirium. Mer utbildning inom ämnet och mer djupgående forskning rekommenderas.

Most health care providers lack the education or clinical training to adequately recognize delirium. and are distressed when caring for patients with delirium (Akechi et al., 2010; Brajtman, Higuchi, & McPherson, 2006; Griffiths, Knight, Harwood, & Gladman, 2014; McCrow, Sullivan, & Beattie, 2014). Early recognition of delirium can improve patient safety and decrease the use of hospital resources (National Institute for Health and Care Excellence, 2014). Although delirium knowledge and recognition are increased after implementation of education and the use of screening tools, more could be done to improve patient outcomes and increase sustainability of knowledge learned (Yanamadala et al., 2013; Soja et al., 2008; van den Boogaard et al., 2009; Pun et al., 2005). The purpose of this DNP project was to explore the perceptions, attitudes and behaviors of ICU nurses in a community hospital when caring for patients with delirium. Findings indicated that most nurses felt delirium is an underdiagnosed problem. Almost all agreed or strongly agreed that assessing ICU patients for delirium is a worthwhile intervention. Interestingly, 38.5% disagreed and 30.7% were neutral that delirium is largely preventative. Despite 69.2% of the participants agreeing that they felt heard by the provider when they suspect the patient is delirious, 76.9% are neutral that they are satisfied with the applied treatment. Despite agreeing that delirium is underdiagnosed, there is lack of knowledge regarding prevention and treatment of delirium. In this ICU, it would be beneficial to tailor the education prior to implementing any delirium screening tools. Results show that education should include: the types of delirium, delirium prevention strategies, RASS scales, importance of daily sedation vacations, and treatment. Education should be provided to both the nurses and the providers. In addition to this, "buy in" should be obtained from the providers to ensure that they will use data gathered from screening tools. Prior to implementing any screening tool, examples of screening tools should be provided to the staff, as well as a bedside demonstration to show ease of use. An additional study should be done to assess the sustainability after tailoring education based on perceptions, attitudes, and behaviors.