Sean Whitfield - NURS 3540 - ALG #11 - Complete PDF

ALG 11 - Chapters 30 Mental Health & 26 Neurocognitive Disorders Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of older adults. Research Highlights contain a summary of pertinent current research related to chapter topi...

ALG 11 - Chapters 30 Mental Health & 26 Neurocognitive Disorders Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of older adults. Research Highlights contain a summary of pertinent current research related to chapter topics. Resources for Best Practice provide suggestions for further information for chapter topics and tools for practice. Healthy People boxes refer to goals cited in Healthy People 2030. Clinical judgment and next generation NCLEX examination style questions are located at the end of every chapter. Please review these questions as they are good practice for the exam. I. Factors that influence Mental Health 1. What are your thoughts and beliefs about emotional and mental health concerns of the elderly? Mental health is important at every stage of life and it includes emotional, psychological, and social well-being. As people age, they may experience certain life changes that impact their mental health, such as coping with a serious illness or losing a loved one. Although many people will adjust to these life changes, some may experience feelings of grief, social isolation, or loneliness. When these feelings persist, they can lead to mental illnesses, such as depression and anxiety. Effective treatment options are available to help older adults and people at every stage of life to manage their mental health and improve their quality of life. Recognizing the signs and seeing a health care provider are the first steps to getting treatment. 2. Discuss potential stressors in late life that may lead to mental health concerns. ◦ Abrupt internal and external body changes and illnesses ◦ Other-oriented concerns: children, grandchildren, spouse, or partner ◦ Loss of significant people ◦ Functional impairment ◦ Sensory impairments ◦ Memory impairment (or fear of) ◦ Loss of ability to drive (particularly men) ◦ Acute discomfort and pain ◦ Breach in significant relationships ◦ Retirement (lost social roles, income) ◦ Ageist attitudes ◦ Fires, thefts ◦ Injuries, falls ◦ Major unexpected drain on economic resources (house repair, illness) ◦ Abrupt changes in living arrangements to a new location (home, apartment, room, or institution) ◦ Identity theft and fear of scams 3. Discuss factors contributing to mental health and wellness in late life. What are some factors that may influence mental health care? ◦ Health and fitness ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ A sense of control over events Awareness of self and others Patience and tolerance Resilience Hardiness Resourcefulness Social support A strong sense of self 4. Discuss the effect of chronic mental health problems on individuals as they age. In acute care settings, nurses will encounter older adults with mental health disorders in emergency departments or in general medical-surgical units. Admissions for medical problems are often exacerbated by depression, anxiety, cognitive impairment, substance abuse, or chronic mental illness, and these conditions are often unrecognized by primary care providers. Nurses who can recognize cues of mental health problems early and seek consultation and treatment will enhance timely recovery. Advanced practice psychiatric nursing consultation is an important and effective service in acute care settings. 5. Discuss anxiety and depression in the older adult and describe appropriate assessment and treatment for each.  Establish a therapeutic relationship and come to know the person.  Listen attentively to what is said and unsaid; pay attention to nonverbal behavior; use a nonjudgmental approach.  Support the person’s strengths and have faith in the person’s ability to cope, drawing on past successes.  Encourage expression of needs, concerns, and questions.  Screen for depression.  Evaluate medications for anxiety side effects; adjust as needed.  Manage physical conditions.  Accept the person’s defenses; do not confront, argue, or debate.  Help the person identify precipitants of anxiety and their reactions.  Teach the person about anxiety, symptoms, and their effects on the body.  If irrational thoughts are present, offer accurate information while encouraging the expression of the meaning of events contributing to anxiety; reassure of safety and your presence in supporting them.  Intervene when possible to remove the source of anxiety.  Encourage positive self-talk, such as “I can do this one step at a time” and “Right now I need to breathe deeply.”  Teach distraction or diversion tactics; progressive relaxation exercises; deep breathing.  Encourage participation in physical activity, adapted to the person’s capabilities.  Encourage the use of community resources such as friends, family, churches, socialization groups, self-help and support groups, and mental health counseling Important Fact: Evidence shows that anxiety may be predictive of cognitive decline, but anxiety also develops in response to cognitive decline (Fung et al., 2018) Important Fact: Women have higher rates of anxiety than men. Anxiety rates drop after the age of 75. (Canuto et al., 2018) 6. What is likely to be different in the appearance of depression in a person who is 70 years old compared to its appearance in a person who is 20 years old? Making the diagnosis of depression in older adults can be challenging, and symptoms of depression present differently in older adults. Primary care physicians accurately recognize less than one-half of patients with depression (Mental Health America, 2021). Older adults who are depressed report more somatic complaints, such as insomnia, loss of appetite, weight loss, memory loss, and chronic pain. It is often difficult to distinguish somatic complaints from the physical symptoms associated with chronic illness. Both symptoms must be evaluated. Decreased energy and motivation, lack of ability to experience pleasure, increased dependency, poor grooming and difficulty completing activities of daily living (ADLs), withdrawal from people or activities enjoyed in the past, decreased sexual interest, and a preoccupation with death or “giving up” are also signs of depression in older adults. Feelings of guilt and worthlessness, seen in younger depressed individuals, are seen less frequently in older adults. Important Fact: Depression is the one of the most prominent issues in the elderly. 7. What are risk factors for suicide? In most cases, depression and other mental health problems, including anxiety, contribute significantly to suicide risk. Common precipitants of suicide include physical or mental illness, death of a spouse or partner, substance abuse, chronic pain, limited social support, living alone, financial strain, and a history of suicide attempts. Adults over age 65 who have been diagnosed with an NCD are more than twice as likely to die from suicide compared to older adults who do not suffer from an NCD. The risk of suicide is particularly elevated among adults 65 to 74 years of age and in the first 90 days following a dementia diagnosis. Individuals with frontotemporal dementia are also at a higher risk of suicide death than those with other types of NCDs (Schmutte et al., 2021) (Chapters 25 and 26). How would you assess for suicidal intent in an older adult? If there is suspicion that the older adult is suicidal, use direct and straightforward questions such as the following:  Have you ever thought about killing yourself?  How often have you had these thoughts?  How would you kill yourself, if you decided to do it? Discuss the methods of assessment and your reaction to these. Assessment should include (1) identification of risk factors, medical problems, medications, functional status, nutritional status, personal and family psychiatric history, alcohol or substance drug use, and complete physical and neurological exam; (2) evaluation of cognitive function; (3) screening for depression; (4) psychological strengths, coping skills, spirituality, sexuality, suicidal ideation, past attempts at suicide; and (5) quantity and quality of social support, financial status, legal history, and potential for elder abuse (Butcher & Ingram, 2018). Assessing gun safety is important since gun access is a significant risk factor for suicide in older adults. Chapter 21 provides a protocol for gun safety assessment. The Columbia-Suicide Severity Rating Scale (C-SSRS) is an evidence-based suicide assessment tool used by many hospitals and organizations. Other resources can be found in Box 30.3. 8. Identify indicators of substance abuse in older adults.  Anxiety  Irritability (feeling worried or “crabby”)  Blackouts  Dizziness  Indigestion; heartburn  Sadness or depression  Chronic pain  Excessive mood swings  New problems making decisions  Lack of interest in usual activities  Social isolation  Out of touch with family or friends  Falls  Bruises, burns, or other injuries  Family conflict, abuse  Headaches  Incontinence  Memory loss  Poor hygiene  Poor nutrition  Insomnia  Unusual response to medications  Frequent physical complaints and physician visits  Financial problems 9. Discuss the various situations that may result in elder substance abuse and ways to effectively intervene. Box 30.21 Recognizing and Analyzing Cues to Potential Alcohol Problems in Older Adults ◦ Anxiety ◦ Irritability (feeling worried or “crabby”) ◦ Blackouts ◦ Dizziness ◦ Indigestion; heartburn ◦ Sadness or depression ◦ Chronic pain ◦ Excessive mood swings ◦ New problems making decisions ◦ Lack of interest in usual activities ◦ Social isolation ◦ Out of touch with family or friends ◦ Falls ◦ Bruises, burns, or other injuries ◦ Family conflict, abuse ◦ Headaches ◦ Incontinence ◦ Memory loss ◦ Poor hygiene ◦ Poor nutrition ◦ Insomnia ◦ Unusual response to medications ◦ Frequent physical complaints and physician visits ◦ Financial problems Treatment and intervention strategies include cognitive behavioral approaches, individual and group counseling, medical and psychiatric approaches, referral to Alcoholics Anonymous, family therapy, case management and community and home care services, and formalized substance abuse treatment. Treatment outcomes for older adults have been shown to be equal to or better than those for younger people. 10. What type of teaching would you provide to an older adult related to the use of alcohol and medications? Providing education about alcohol use to older adults and their families and referring to community resources are important nursing roles and essential to best practices. Important: Medications Interacting with Alcohol are many. Medications that our senior population take on a daily basis can have a deadly interaction with alcohol. 11. Formulate strategies that may be used to promote mental health and wellness in late life. USING CLINICAL JUDGMENT TO PROMOTE HEALTHY AGING: MENTAL HEALTH Assessment of mental health includes examination of cognitive function and conditions of anxiety and adjustment reactions, paranoia, substance use, depression, and suicidal risk. Assessment of mental health also must focus on social intactness and affective responses appropriate to the situation. Attention span, concentration, intelligence, judgment, learning ability, memory, orientation, perception, problem solving, psychomotor ability, and reaction time are assessed in relation to cognitive intactness and must be considered when making a psychological assessment. Assessment includes specific processes that are intact, as well as those that are diminished or compromised. Obtaining psychosocial assessment data from older adults is best done when the individual is rested and in short sessions after some rapport has been established. Performing repeated assessments at various times of the day and in different situations will give a more complete psychological profile. It is important to be sensitive to a patient’s anxiety, special needs, and disabilities and vigilant in protecting the person’s privacy. The interview should be focused so that attention is given to strengths and skills and life challenges. HEALTHY PEOPLE 2030 Mental Health and Mental Disorder Data from US Department of Health and Human Services: Healthy People 2030 (website), 2020. https://health.gov/healthypeople. Improve mental health through prevention and by ensuring access to appropriate quality mental health services. Increase the proportion of primary care facilities that provide mental health treatment on-site or by paid referral. Increase the proportion of adults with serious mental illness who get treatment. Increase the proportion of homeless adults with mental health problems who receive mental health services. Increase the proportion of adults with depression who get treatment. Reduce the proportion of persons who experience major depressive episodes. Increase the proportion of primary care visits where adults are screened for depression. Reduce the suicide rate. Reduce the proportion of people who had alcohol use disorder in the past year. Increase the proportion of people with a substance use disorder who got treatment in the past year. Increase the proportion of people who get a referral for substance use treatment after an emergency department visit. II. Neurocognitive Disorders 1. Differentiate between delirium, dementia, and depression. Table 26.1 Delirium  Onset → Sudden, abrupt.  Course over 24 hours → Fluctuating, often worse at night.  Consciousness → Reduced  Alertness → Increased, decreased, or variable.  Psychomotor Activity → Increased, decreased, or mixed. Sometimes increased, other times decreased.  Duration → Hours to weeks.  Attention → Disordered, fluctuates.  Orientation → Usually impaired.  Speech → Often incoherent, slow, or rapid; may call out repeatedly or repeat the same phrase.  Affect → Variable but may look disturbed, frightened. Depression  Onset → Recent, may relate to life change; can be chronic  Course over 24 hours → Fairly stable, may be worse in the morning  Consciousness → Clear  Alertness → Normal  Psychomotor Activity → Variable, agitation or retardation  Duration → Variable and may be chronic  Attention → Most often no impairment; however, can see difficulty concentrating  Orientation → Usually normal; may answer “I don’t know” to questions or may not try to answer  Speech → May be slow  Affect → Flat Dementia           Onset → Insidious, slow, over years and often unrecognized until deficits obvious. In vascular dementia will see stair step pattern, so may see sudden change in cognitive function but should always be evaluated. Course over 24 hours → Fairly stable, may see changes with stress; some individuals have more symptoms toward nighttime (sundowning); may see sudden change when microvascular infarct occurs in vascular dementia. Consciousness → Clear. Alertness → Generally normal. Psychomotor Activity → Normal, may have apraxia or agnosia. Duration → Years. Attention → Generally normal but may have trouble focusing. Orientation → Often impaired; may make up answers or answer close to the right thing or may confabulate but try to answer. Speech → Difficulty finding word, perseveration. Affect → Slowed response, may be labile. 2. Differentiate between reversible and irreversible cognitive impairments. The causes of delirium are potentially reversible; therefore early accurate assessment and early identification are critical. Delirium is given many labels: acute confusional state, acute brain syndrome, confusion, reversible dementia, metabolic encephalopathy, and toxic psychosis. Often, mental health professionals classify cognitive disorders into two broad categories: those that are irreversible (i.e., not curable) and those that are reversible (i.e., curable). Dementias are irreversible, progressive, degenerative disorders that gradually reduce a person's ability to function in everyday life. A person with dementia cannot regain his or her previous level of functioning, even though some symptoms may be managed through treatment. Examples of irreversible dementias include Alzheimer's Disease, Lewy Body Dementia, and Dementia caused by the AIDS/HIV virus. On the other hand, the progression of reversible cognitive disorders can be halted by identifying the cause of the symptoms and properly treating the underlying disorder. With appropriate treatment, a person's previous level of functioning can be restored. Examples of reversible cognitive disorders are pseudodementia and delirium, which will be described later. Dementia may occur at any age but affects primarily older people. It accounts for more than half of nursing home admissions. Dementias can be classified in several ways; one way is  Alzheimer or non-Alzheimer type  Cortical or subcortical  Irreversible or potentially reversible  Common or rare Dementia should not be confused with delirium, although cognition is disordered in both. The following helps distinguish them:  Dementia affects mainly memory, is typically caused by anatomic changes in the brain, has slower onset, and is generally irreversible.  Delirium affects mainly attention, is typically caused by acute illness or drug toxicity (sometimes life threatening), and is often reversible. 3. Discuss the assessment of an older adult with cognitive impairment. In contrast to delirium, major and mild NCDs typically have a gradual onset and a slow, steady pattern of decline without alterations in consciousness. These disorders represent serious pathological alterations and require assessment and interventions. However, a change in cognitive function in older adults is often seen as normal and therefore is not investigated. Any change in mental status in an older adult requires a comprehensive geriatric assessment with a strong focus on cognitive function (Chapter 9). 4. Identify precipitating factors for delirium. Box 26.2 Box 26.2 Precipitating Factors for Delirium Age greater than 65 years Cognitive impairment Severe illness or comorbidity burden Hearing or vision impairment Current hip fracture Presence of infection Inadequately controlled pain Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, antihistamines, antipsychotics) Depression Alcohol use Sleep deprivation or disturbance Renal insufficiency Aortic procedures Anemia Hypoxia or hypercarbia Poor nutrition Dehydration Electrolyte abnormalities Poor functional status Immobilization or limited mobility Risk of urinary retention or constipation Use of invasive equipment, restraints 5. Discuss nursing interventions for prevention of delirium. Box 26.7 Tips for Best PracticePrevention of Delirium Sensory enhancement (ensuring eyeglasses, hearing aids, listening amplifiers) Mobility enhancement (ambulating at least twice a day if possible) Bedside presence of a family member whenever possible Cognitive orientation and therapeutic activities (tailored to the individual) Pain management Cognitive stimulation (if possible, tailored to individual’s interests and mental status) Simple communication standards and approaches to prevent escalation of behaviors Nutritional and fluid repletion enhancement Sleep enhancement (sleep hygiene, nonpharmacological sleep protocol) Medication review and appropriate medication management Adequate oxygenation Prevention of constipation Minimize the use of invasive medical devices, restraints, or immobilizing devices Pay attention to environmental noise, light, temperature Normalize the environment (provide familiar items, routines, clocks, calendars) Minimize the number of room changes and interfacility transfers 6. Describe nursing models of care for persons with dementia. Progressively Lowered Stress Threshold Model The PLST model (Hall, 1994; Hall & Buckwalter, 1987) was one of the first models used to plan and evaluate care for people with NCDs in every setting. The model suggests that environmental antecedents produce stress, which is met by a coping response that is compromised by the impact of dementia (Scales et al., 2018). Symptoms such as agitation are a result of a progressive loss of the person’s ability to cope with demands and stimuli when the person’s stress threshold is exceeded. An example is the person who becomes agitated in response to excess noise in the environment (loudspeaker, loud talk). Using this model, care is structured to decrease the stressors and provide a safe and predictable environment. Positive outcomes from use of the model include improved sleep; decreased sedative and tranquilizer use; increased food intake and weight; increased socialization; decreased episodes of aggressive, agitated, and disruptive behaviors; increased caregiver satisfaction with care; and increased functional level. Stressors Triggering BPSDs (PLST Model) Fatigue Change of environment, routine, or caregiver Misleading stimuli or inappropriate stimulus levels Internal or external demands to perform beyond abilities Physical stressors such as pain, discomfort, acute illness, and depression Principles of Care Derived From the PLST Model 1. Maximize functional abilities by supporting all losses in a prosthetic manner. 2. Establish a caring relationship and provide the person with unconditional positive regard. 3. Use patient behaviors indicating anxiety and avoidance to determine appropriate limits of activity and stimuli. 4. Teach caregivers to try to find causes of behavior and to observe and evaluate verbal and nonverbal responses. 5. Identify triggers related to discomfort or stress reactions (factors in the environment, caregiver communication). 6. Modify the environment to support losses and promote safe function. 7. Evaluate care routines and responses on a 24-hour basis and adjust the plan of care accordingly. 8. Provide as much control as possible; encourage self-care, offer choices, explain all actions, do not push or force the person to do something. 9. Keep the environment stable and predictable. 10. Provide ongoing education, support, care, and problem solving for caregivers. Need-Driven Dementia-Compromised Behavior Model The NDB model (Algase et al., 2003; Kolanowski, 1999; Richards et al., 2000) is a framework for the study and understanding of behavioral symptoms. All behaviors have meaning and are a form of communication, particularly as verbal communication becomes more limited. The NDB model proposes that the behavior of persons with NCDs carries a message of need that can be addressed appropriately if the person’s history and habits, physiological status, and physical and social environment are carefully evaluated. Rather than behavior being viewed as disruptive, it is viewed as having meaning and expressing needs. Behavior reflects the interaction of background factors (cognitive changes resulting from dementia, gender, ethnicity, culture, education, personality, responses to stress) and proximal factors (physiological needs such as hunger or pain, mood, physical environment [e.g., light, noise, temperature]) with the social environment (e.g., staff stability and mix, presence of others). Optimal care is provided by manipulating the proximal factors that precipitate behavior and by maximizing strengths and minimizing the limitations of the background factors. For instance, sleep disruptions are common in people with an NCD. If the person is not getting adequate sleep at night, agitated or aggressive behavior during the day may signal the need for more rest. Interventions to modify proximal factors interfering with sleep, such as noise, frequent awakenings during the night, and daytime boredom, can help meet the need for rest and sleep and decrease agitation or aggression. Person-Centered Nursing Actions in Care of Individuals With Neurocognitive Disorders Get to know the person. Build and nurture authentic caring relationships. Recognize and accept the person’s reality. Obtain input from the individual and engage in shared decision making to the extent possible. Maximize abilities to make choices. Structure daily living to maximize remaining abilities and support limitations. Identify characteristics of the social and physical environment that may cause distress for the person or exacerbate behavior and psychological symptoms. Provide meaningful activities and relationships to enhance quality of life. Ensure safety. Monitor general health and impact of the neurocognitive disorder on management of other medical conditions. Collaborate with caregivers in the areas of problem solving, resource access, long-range planning, emotional support, and respite. Support advance care planning and advance directives. 7. Discuss common concerns in care of persons with dementia and nursing responses. The major care concerns for patients, families, and staff caring for individuals with major NCDs include nutrition, ADLs, maintenance of health and function, safety, communication, behavioral changes, caregiver needs and support, and quality of life. Five common care concerns for individuals with a diagnosis of a major NCD and nursing actions are discussed in the remainder of this chapter: communication, behavior concerns, ADL care, wandering, and nutrition. Caregiving for persons with NCDs is discussed in Chapter 32, and other care concerns, such as falls and incontinence, are discussed in earlier chapters of this book. 8. Identify community and Internet resources for clients with dementia and their caregivers. Resources for Best Practice Delirium and Dementia ◦ Advance Directive for Dementia: http://www.dementia-directive.org. ◦ American Geriatrics Society: CoCare: HELP program (formerly the Hospital Elder Life Program). https://help.agscocare.org/. ◦ Critical Illness, Brain Dysfunction, and Survivorship (CIDS) Center: Descriptions of ICU stay, delirium experience, https://www.icudelirium.org/patients-and-families/patienttestimonials. ◦ Confusion Assessment Method for the ICU (CAM-ICU) instrument, https://www.icudelirium.org/medical-professionals/delirium/monitoring-delirium-in-theicu. ◦ Delirium Network.org: Family Confusion Assessment Method (FAM-CAM). https://deliriumnetwork.org/wp-content/uploads/2018/05/FAM-CAM.pdf. ◦ Hartford Institute for Geriatric Nursing: Dementia series. https://hign.org/consultgeri/trythis/dementia. ◦ ICU-DIARY.org: Informal network for all health care workers interested in the ICU diary. http://www.icu-diary.org/diary/start.html. ◦ Nursing Home Toolkit: Promoting positive behavioral health. http://www.nursinghometoolkit.com/. ◦ Society of Critical Care Medicine: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU. https://www.sccm.org/ClinicalResources/Guidelines/Guidelines/Guidelines-for-the-Prevention-and-Management-of-Pa. ◦ VA.gov: Confusion Assessment Method (CAM). https://www.va.gov/covidtraining/docs/The_Confusion_Assessment_Method.pdf. Audio/Video Focus Areas Please watch the following videos and answer the questions provided. 1. Elderly - Depression and Suicide in Old Age Senior Health Center Everyday Health (4:49) Which gender is less likely to seek treatment for depression? Older men Medications for chronic illness have that lead to depression and memory loss. Untreated depression can lead to Depression can lead to a 50% higher risk for dementia. Clinical depression is caused by an imbalance in the brain chemistry. Which neurotransmitter is turned OFF? Serotonin. What activities does the doctor suggest to increase serotonin? Exercise, eat well, manage stress, smile and do nice things for yourself. 2. Depression as we get older - darkness then light (4:59) A story of life. “The Silent Scream” 3. Living with Dementia (10:22) Describe the feelings felt by each individual interviewed in this short film. Fear. Doubt. Unsure. Self isolation. Disassociation from the world. Defeated. Not human. Guilt. Unfocused. Hallucinations. Disoriented. Visual impairment. Powerless. Loneliness. Attacked by a “thing.” Bothered by a persistent spy. What forms of support did you witness? Family, friends and professional support staff. Application Questions or Case Studies The following case studies were retrieved from the textbook: Touhy, T.A., & Jett, K.F. (2020). Ebersole & Hess' toward healthy aging: Human needs & nursing response (10th ed.). Elsevier. You are a nurse on a busy medical unit in a large metropolitan medical center. At 3:00 PM, you admit an 81-year-old patient to your unit with a diagnosis of pneumonia. She decided not to get an influenza vaccine this year and developed influenza followed by pneumonia. Her primary care physician treated her with a course of oral antibiotics, but when she did not improve, he admitted her to the hospital. She has a history of hypertension, hypothyroidism, and osteoarthritis. You complete her nursing admission assessment. She is independent in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and she walks with a steady gait. She is alert and oriented. She is widowed and lives independently in the community. She is a retired surgical nurse. She is easily engaged and talkative. She tells you that you remind her of her granddaughter, who is also a nurse. She tells you that she usually wears eyeglasses but that she dropped them and broke them yesterday and that her daughter is taking them to be repaired. She also has a hearing aid in place. You orient her to the unit, insert her IV, and administer her first dose of antibiotics. After you give report to the oncoming shift, you stop to say goodbye to her, and she tells you that she will see you tomorrow. When you get a report from the night shift at 7:00 AM the following morning, you are surprised by the report. The night nurse reports that the woman has been up all night long, was agitated, climbed out of bed, and sustained a fall. In addition, she is incontinent of urine. You immediately go to see her. She is sitting up in bed and has pulled out her IV. She thinks that you are her daughter and states, “Please get me out of here. There are bad people here, and they stand and look at you and laugh at you. They tried to poison me.” She is not wearing her hearing aid and will not allow you to insert it. You attempt to reorient her with little success. 1. What do you think has happened to the woman? Rare type of reaction to the Vancomycin. Provide a rationale for your answer. S/S Level of consciousness change, loss of hearing, fall (possibly due to unusual tiredness or weakness, numbness or tingling in feet). Possibly developed hypercapnia as a result of increased CO2 in the blood due to pneumonia diagnosis. 2. What are some possible precipitating factors in her case? Impaired gas exchange r/t pneumonia. Possible increased CO2 in the blood. 3. What is your first priority for this patient? Stop the Vancomycin. Since IV has been pulled out, check catheter for integrity. Contact healthcare provider to assess the severity of the reaction. 4. How do you assess for delirium in an older adult? The diagnosis of delirium is made on the basis of clinical history, behavioral observation and cognitive assessment. The history should confirm that an acute change in baseline cognitive function has occurred. Attention can easily be measured at the bedside with simple tests such as digit span or recitation of the months of the year backwards. For patients in the ICU who are unable to speak, assessment methods such as the Intensive Care Delirium Screening Checklist or the Confusion Assessment method for the ICU. 5. List three interventions that you can implement that would help manage the woman’s delirium, and explain how they would help. Use short to the point questions. Allow them time to gather thoughts and respond. Effective communication. Assess ear canal for earwax buildup. Check hearing aids to make sure they are in good working order. Improve communication. Play music in the room or massage patient. Increase relaxation.