Cholecystectomy & Delirium Case Study: Please share thoughts

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Specializes in None yet..

Okay, maybe I posted in the wrong space so I'm trying here.

Okay, I am really stuck on writing a paper. We need to use the nursing process to develop and create care plans for one "psychological" nursing diagnosis and two "medical" nursing diagnoses.

Patient is a 74 year-old obese female admitted for an open cholecystectomy. Patient was alert, oriented x 4 and compliant with requests during day shift. She also received 30 mg of oxycodone PRN in the 8 hours before shift change; her max PRN dosage is 20 mg/8 hours (5-10 mg/4hrs).

Patient tries to get out of bed 2 hours after shift change, hallucinating snakes under the bed. She has tremors in her hands when they are extended and is oriented to person only. You give her 2 mg of lorazepam for anxiety and 40 minutes later, she hits you in the face when you try to check her dressing. Her wound is held together with steri-strips and covered by gauze.

I can think of many diagnoses but I'm not sure how to prioritize them. The best "psych" diagnosis would seem to be "Risk for Other- or Self-Directed Violence." Chronic confusion is given in our psych text, but there is nothing to indicate that this is chronic and not acute. Technically, "acute confusion" is a medical diagnosis as it comes from Carpenito... or is it psych because it obviously deals with mental state.

There is nothing about pain...

Davis Drugs says the max dose of lorazepam for geriatric patients is 0.5mg and that it potentiates the respiratory depression of opioid analgesics. Upper GI surgeries commonly cause shallow breathing. But there is nothing in the scenario about respirations or info on effects of lorazepam or oxy, for that matter. Is it making things up to be concerned about Risk for Impaired Breathing Pattern, given these facts?

When I sort through everything, trying not to bring in anything not in the scenario, I think of Risk for Trauma, Risk for Falls, Risk for Infection are important. Too many risks, right? Self-Care deficit... but that's assuming facts not given explicitly.

I don't know how to think about this. Our instructors have said they won't answer these sort of questions. (Citation I know. It's how to decide among the gazillions of NDs that I need to know... and that is not taught much in class.)

So... I'm going to take a break and go for a brisk walk in the rain. Can anyone help me figure out how to think about this assignment? What knowledge can I bring into my assessment? How do I pick the priority diagnoses? I want to pick acute confusion because if THAT is successfully treated, the self-care deficits, risk for violence, etc. are probably solved. But is that a psych diagnosis if it's not listed in Townsend? Preventing violence doesn't solve the problems that would give rise to the other diagnoses.

I'm really discouraged. My brain is just not working well on this, I'm getting anxious, and I'm getting WAY black-and-white in my thinking as in "I'll fail out of nursing school" and "I don't have what it takes to be a nurse.

I hope someone can help me to focus and make reasoned judgments. I'm not being lazy, just stupid, I fear. (Have I hit a wall? I have had good grades so far and I am a tutor. But this just feels so overwhelming...)

PS. I decided on Acute Confusion for my psych diagnosis. This leaves me with two risk diagnoses in the lead... which doesn't feel right.

Specializes in None yet..

What do you think about Risk for Trauma for one of the medical nursing diagnoses?

Specializes in Emergency.

I do like delirium as a psych nursing diagnosis. I think now at this point, you need to figure out why this patient may be experiencing delirium.

Postoperative delirium in the elderly: diagnosis and management

Is this patient at risk for infection? Because of delirium, is this patient at risk for falls? Because this is an abdominal surgery, what other thing could this patient be at risk for? (Think pulmonary). What can cause delirium?

Specializes in None yet..

I think the delirium is primarily the result of overmedication. She was given 50% more oxy than her max dose. She was given 4 times the recommended daily dose of Ativan for someone over age 65. Benzos are second or third-line treatments for delirium in the geriatric population; they can paradoxically increase s/s of dementia. Haldoperidol is the drug of choice. Age over 65 years increases the risk for post-op dementia.

Additionally, the patient probably has had sleep disturbance related to the cholecystitis that necessitated her surgery. Surgery and the hospital environment has probably exacerbated this. However, this is not explicitly stated in the prompt so I'm thinking I shouldn't comment on facts not in evidence... including pain which I would expect to be a primary concern. (Maybe not so much given her drug dosages.)

Similarly, I would be concerned about risk of impaired breathing pattern due to the high level of opiates and the potentiating effects of the benzo... but again, the prompt says nothing about respiration so I'm again thinking I shouldn't go there. On the other hand, that is a RISK diagnosis, so I don't need defining characteristics. The type of surgery and her meds would be risk factors for this. I'm thinking that using knowledge of drug actions and effects in an assignment like is not the same as making up assessment data that is not explicitly stated.

I also like risk for trauma r/t impaired mobility secondary to upper GI surgery, effects of pain medication and sedatives, impaired sensorium and visual hallucinations, faulty judgment secondary to cognitive defects, and upper abdominal incision secured w/ steri-strips and gauze.

Pulmonary complications are certainly a concern with upper GI surgery but the prompt doesn't indicate any preop risks or post op complications like pneumonia, pneumonitis, atelectasis, bronchitis, pulmonary emboli and/or acute respiratory failure. Along the same line, I'd expect acute pain, impaired physical mobility, and other issues... but again, no assessment data in the prompt.

Risk for infection, another one I'd normally put high on the list because it was GI surgery and she's resisting assessment of the wound site. But is that enough?

I have been told (I believe correctly) that I overthink things so I am really trying to focus on "just the facts, Ma'am!"

Would I be okay with acute confusion, risk for trauma and risk for ineffective breathing pattern? These last two would not be my highest common sense priorities but trying to use only the prompts, they seem like the strongest.

Thank you so much for your help. You would not believe all the time I've spent on this! It's embarrassing.

In the large academic medical center psychiatric consultation/liaison service in which I work, benzos aren't considered "second or third line treatments" for delirium -- they're considered contraindicated, period. The entire benzo group is one of the classes of medications considered deliriogenic, and they make delirium worse, not better (in anyone, regardless of age). Haldol or one of the atypical antipsychotics are considered the drugs of choice.

In terms of nursing dxs, I would be thinking about altered sensory perception (the hallucinations), acute confusion, and alterations of operations of thought.

The thing I enjoy about delirium is that the most effective interventions are nursing interventions that require no physician orders or special equipment or materials, including: reorient frequently; maintain a strong circadian schedule and cues (lights on and blinds up during the day, lights off and blinds closed at night); group nursing tasks/care as much as possible to permit long intervals of uninterrupted rest/sleep at night; minimize exposure to deliriogenic drugs (opioids, benzos, antihistamines, anticholinergics) -- but pain is one of the risk factors for delirium, so you do want to treat pain adequately; and encourage family to visit and to bring in photos and other familiar objects from home to display in the room. (I don't have any sources for those handy, but I'm sure they're not hard to find.)

Delirium is not a psychiatric diagnosis, specifically (it's really more of a neuro issue), and ditto for acute confusion. And I would consider it a high priority, since it has a high mortality rate if untreated.

Best wishes --

Specializes in None yet..
In the large academic medical center psychiatric consultation/liaison service in which I work, benzos aren't considered "second or third line treatments" for delirium -- they're considered contraindicated, period. The entire benzo group is one of the classes of medications considered deliriogenic, and they make delirium worse, not better (in anyone, regardless of age). Haldol or one of the atypical antipsychotics are considered the drugs of choice.

In terms of nursing dxs, I would be thinking about altered sensory perception (the hallucinations), acute confusion, and alterations of operations of thought.

The thing I enjoy about delirium is that the most effective interventions are nursing interventions that require no physician orders or special equipment or materials, including: reorient frequently; maintain a strong circadian schedule and cues (lights on and blinds up during the day, lights off and blinds closed at night); group nursing tasks/care as much as possible to permit long intervals of uninterrupted rest/sleep at night; minimize exposure to deliriogenic drugs (opioids, benzos, antihistamines, anticholinergics) -- but pain is one of the risk factors for delirium, so you do want to treat pain adequately; and encourage family to visit and to bring in photos and other familiar objects from home to display in the room. (I don't have any sources for those handy, but I'm sure they're not hard to find.)

Delirium is not a psychiatric diagnosis, specifically (it's really more of a neuro issue), and ditto for acute confusion. And I would consider it a high priority, since it has a high mortality rate if untreated.

Best wishes --

Thank you so much! This really helps, especially knowing that delirium aka confusion is not a psych diagnosis. Valuable info on the benzos! My source for that WAS kind of old.

Specializes in Family Nurse Practitioner.

I only read the first half of your post. This is an elderly larger woman still under the effects of anesthesia, a real cause for delirium. Plus, she is being given oxycodone on top of that. I think the hallucinations can be a reaction to the oxycodone plus anesthesia. She has the right to shake and be anxious because she really does see snakes under her bed. The orientation level can be explained by the delirium. Pain can also cause delirium. The PO oxycodone may not be cutting it for her pain, especially if she is a larger woman. She may have also picked up a UTI or post op infection while on the table since they may have put in a foley - especially if it was an open chole. Choles usually start out laproscopic, if it turned to open, there was a reason for that. Did her gallbladder burst? She could have peritonitis. Infection can also cause delirium. I think ativan was a wrong move. Not the dose necessarily, since she is a larger woman, but some elderly patients do not do well with benzos and they can actually make them more confused and delirious. It seems like they are throwing ativan at the patient instead of checking labs, stopping the narcs for now, checking a temp, and checking urine. Oh, and check to make sure she didn't throw a clot somewhere. Is the patient breathing ok?

Specializes in Med/Surg.

Is there a history of ETOH use at home ? Elderly pts often do not voice ETOH use and families don't bring up that grandma has a bedtime drink or more.

Specializes in None yet..
I only read the first half of your post. This is an elderly larger woman still under the effects of anesthesia a real cause for delirium. Plus, she is being given oxycodone on top of that. I think the hallucinations can be a reaction to the oxycodone plus anesthesia. She has the right to shake and be anxious because she really does see snakes under her bed. The orientation level can be explained by the delirium. Pain can also cause delirium. The PO oxycodone may not be cutting it for her pain, especially if she is a larger woman. She may have also picked up a UTI or post op infection while on the table since they may have put in a foley - especially if it was an open chole. Choles usually start out laproscopic, if it turned to open, there was a reason for that. Did her gallbladder burst? She could have peritonitis. Infection can also cause delirium. I think ativan was a wrong move. Not the dose necessarily, since she is a larger woman, but some elderly patients do not do well with benzos and they can actually make them more confused and delirious. It seems like they are throwing ativan at the patient instead of checking labs, stopping the narcs for now, checking a temp, and checking urine. Oh, and check to make sure she didn't throw a clot somewhere. Is the patient breathing ok?[/quote']

Foley is producing clear, yellow urine. No info about whether the operation started as a laproscopic procedure or was open from the start. Good point about delirium being a s/s of UTI.

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