Week 10 Psychosis_ ICU Delirium PDF

Looking Ahead Next Week Due this Sunday: CJE- MS2 Benchmark Exam Psychosis Discussion Board Review Day Davis Post Class Quiz: Psychosis Plan of Care Saunders: Psychosis & Mobility Final Evals CJE Remediation Wishing...

Looking Ahead Next Week Due this Sunday: CJE- MS2 Benchmark Exam Psychosis Discussion Board Review Day Davis Post Class Quiz: Psychosis Plan of Care Saunders: Psychosis & Mobility Final Evals CJE Remediation Wishing you a peaceful Thanksgiving  Psychosis ICU Delirium NURS 440 George Fox University, College of Nursing Learning Objectives 1. Review the introduction to psychosis including anatomy and physiology and pathophysiology and risk factors. 2. Outline the pathophysiology of the psychosis as it relates to the ICU- delirium. a. Polypharmacy b. ICU admission (Infection, Illness, Sensory) c. Acronyms THINK & DELIRIUM 3. Document assessment findings for the patient with ICU-delirium (RASS, CAM-ICU) 4. Use nursing judgment to plan safe, evidence-based care for psychosis as it relates to Induced psychosis (ICU-delirium). (ABCDEF bundle) 5.Apply pharmacology knowledge to delineate nursing implications for administering medications to treat psychosis as it specifically relates to Induced psychosis. 6. Collaborate with the health care team in the management of ICU delirium. 7. Apply knowledge of pathophysiology to reduce potentially life-threatening complications for the person with ICU delirium as it relates to psychosis.(ABCDEF Bundle) 8. Provide health teaching for the patient and family regarding Induced psychosis as it relates to psychosis. 9. Evaluate the effectiveness of nursing care as it relates to professional practice within the context of the hospital induced psychosis/delirium. Exemplar: Induced psychosis & Polypharmacy with specific example or focus on ICU delirium Video- Patient Perspective What is Psychosis? Psychosis is defined as abnormalities in five different symptomatic domains: delusions,hallucinations, disorganized thought, disorganized or abnormal motor behavior and negative symptoms.(DSM5 definition) What is ICU delirium? Acute onset of cerebral dysfunction characterized by 3 features: A change or fluctuation in baseline mental status Inattention Either disorganized thinking or altered level of consciousness ICU-Delirium Risk Factors Risk Factors: Older age THINK DELIRIUM Toxic Situations HF, shock dehydration, new kidney or liver Drugs failure, sedatives Eyes, ears other sensory deficits Hypoxia Infection (sepsis) immobility Low O2 states Nonpharmacologic -being ignored Infection glasses, sleep protocol, noise control, Ambulation, music Retention (urine & stool) K+ or electrolyte problems Intracranial (rare) seizure,stroke Under Hydration /Undernutrition Metabolic Causes- Electrolytes ICU Delirium Pathophysiology Neurotransmitter Aging Brain Dysregulation Neuro Inflammation Systemic inflammation Hypoxia Mitochondrial Dysfunction Classification Hyperactive ○ Agitation, Restlessness, Hallucinations,Emotional changes Hypoactive ○ Confusion, Lethargy, Sedation, Slowed motor function Mixed RS ICU day #2 RS is a 72 year old female who remains in the surgical ICU after an emergent surgical repair of a right hip fracture BP 98/63 HR 110 RR 21 RASS -3 CAM-ICU negative Mechanically ventilated- she failed a spontaneous breathing trial this am She is tolerating tube feeds at 20mL/hr She is receiving fentanyl 25-50 mcg IV push Q4 hours PRN pain Propofol 30 mcg/kg/min for sedation She has not left the bed since she arrived to the emergency department Prior to admission she enjoyed bridge and golfed weekly Diagnostic Tests for [Exemplar] CAM-ICU pCAM- ICU psCAM-ICU ICDSC CAM ICU- Scale & Video how to This is not my mom! Key Nursing Management for Delirium A- Assess & Manage Pain B- Both awakening and Breathing Trials C- Choice of sedation and analgesia medications D- Delirium Assessment E- Early progressive mobility F- Family engagement and empowerment Assess for Pain Pain Management Assess for Pain routinely Premedicate for procedures,therapy, repositioning Treat pain prior to considering sedation Pain Management- opioid alternatives Acetaminophen IV, PO, PR Nefopam Ketamine- low dose Neuropathic- gabapentin, carbamazepine Massage Music Cold Both Awakening and Breathing Trials Both Awakening and Breathing Trials Coordinate with Respiratory Therapy, Provider Wean sedation (turn off) Assess neuro status Assess ability to breath on own Choice of sedation and analgesia medications Choice of sedation and analgesia medications Dexmedetomidine or Propofol instead of Benzodiazepines for sedation Use the lightest level of sedation needed goal RASS -2 or higher How would you assess for effectiveness of RS’s sedation? 1. Evaluate for asynchrony with the vent (breathing against the machine) 2. Use a validated tool such as RASS 3. Ask the family if they believe she is comfortable 4. Begin monitoring brain waves with BIS Delirium Assessment Delirium Assessment Should be done at least once per shift Early progressive mobility Early Mobilization Family engagement and empowerment Other non pharmaceutical Promote sleep and wake cycles Reorient Minimize or disguise lines and tubes Avoid Restraints Medications Haloperidol (Haldol) Risperidone Olanzapine Quetiapine Dexmedetomidine or Propofol instead of Benzodiazepines for sedation 72 year old patient with RASS -2 positive CAM-ICU score. HR 88 BP 102/64 RR 16 On the ventilator, Fentanyl 100mcg/hr, Dexmedetomidine 0.6mcg/kg/min What will the nurse consider as the priority for intervention? 1. Start a low-dose antipsychotic (haloperidol) 2. Begin intermittent bolus doses of benzodiazepine 3. Discontinue the dexmedetomidine and fentanyl 4. Ensure all elements of the ABCDEF bundle are being followed Making Connections: Interrelated Concepts Extend the learning beyond this class… Build a POC using the class template for our case study patient Mr. Willis Compare and contrast signs and symptoms of Alzheimer's with ICU Delirium Review the discussion board and comment or ask questions on your classmates posts. Wrapping it up Key takeaways or lingering questions?