Delirium & neuro patients

[carolelainern, BSN, RN]

Something that's been kind of on my mind lately...I work in a trauma/neuro ICU. One of the big pushes lately from the higher-ups at my hospital has been towards delirium detection and prevention. If anything, I think this has arrived to us a little late. As far as nursing interventions in this area go, mobility is obviously a huge one, but another is promoting sleep. We're supposed to chart things we do to promote sleep in our patients...turning down lights at night, minimizing inappropriate alarms, etc. To be clear, I'm completely on board with these things, but one thing that never gets mentioned is the frequency with which we awaken patients to do neuro checks overnight. Obviously these are people who already have a neurological insult of some sort. Of course I know why we do frequent neuro checks, but sometimes I feel like we drastically overdo it, like hourly neuros in patient who has been neurologically stable for days to weeks. I'm curious if anyone works in a neuro ICU where frequent neuro checks are being re-evaluated or decreased in order to promote sleep and possibly help prevent delirium. I'm curious as well if anyone knows of any literature out there that either defends frequent neuros, or the opposite-ties them to increased delirium and possibly worse cognitive outcomes.

[KeepinitrealCCRN]

or patients on nimodipine q2 for 1 week. if they aren't delirious after that then they are all stars.

[Rosie_one]

I work in a neurotrauma unit and unfortunately hourly neuros are part of it. I would ask the neueo surgeons if it's safe to change frequency of neuro obs. It depends on what's the problem, but they won't risk changing to even second hourly if there is still a slight risk of deterioration.

There are some really good Danish research articles into icu delirium. You've named a few things, also if you can reduced sedation(may not be able to depending on reason for admission). Several articles recommended reducing propofol by half, if can tolerate then leave at halved rate. If can't, go back up and try again a bit later and work to a RASS scale aim instead. We often oversedate our patients for our own and families comfort. Difficult to not have delirium in neuro sadly.

[myoglobin, ASN, BSN, MSN]

Consider, that better than 50% of patient over 50 in the ICU will have delirium (according to many studies). I get frustrated with this topic because delirium is "almost the norm" for significantly sick, ICU, patients especially if they are older. Now if they were to offer truly useful interventions (such as playing classical music, or providing access to high quality audio books, none of which have research of which I am aware), then I would be "all over" looking at ways to mitigate the issue. Heck, you could take a 25 year old Navy Seal, and if you wake him up every hour for even two days you could probably induce delirium in a high percentage of the cases simply from REM sleep deprivation (indeed the CIA has used a variation of this tactic on suspected terrorists precisely for this purpose).

[LovingLife123]

I try to get my Neuro patients off of q1 Neuro checks as quickly as possible. It gets to a point where you can’t really tell if there are Neuro changes or it’s that they are exhausted. It’s gets very frustrating.

The absolute best thing for especially the elderly is to get those discontinued as soon as possible and out of the icu.

I completely understand the need for frequent monitoring. But say, you are not going to do any interventions with the patient. This often happens with our neurosurgery patients. They may have a small bleed where surgery is not necessary or the bleed is in an area of the brain where surgery can not be done. I can’t understand the neurosurgeons rationale for 3 days of q1 checks. And the physicians get crappy when you ask to change them and have gone to our manager about us asking them.

Delirium can be deadly in the elderly. I constantly advocate for the discontinuing of them unless they are a fresh Neuro admit or their Neuro status has changed recently.

[myoglobin, ASN, BSN, MSN]

The MD want the “textbook” liability protection of the neurochecks without the burden of dealing with their futility. They will decline to intervene with changes and still often blame nursing. They basically want you to lie and then take the fall on those rare occasions a bad outcome occurs.

[carolelainern, BSN, RN]

Yes! I cannot tell you how many times I've escalated a change, and the response is... "monitor." Ugh.

I just had an 18 year old frontal TBI. He's impulsive and irritable as hell. Not a surgical candidate. 5 days of q1 neuros. Did we do them? Uh, no. Basically you end up deciding between fudging some charting and harming your patient

[myoglobin, ASN, BSN, MSN]

20 minutes ago, carolelainern said:

Yes! I cannot tell you how many times I've escalated a change, and the response is... "monitor." Ugh.

I just had an 18 year old frontal TBI. He's impulsive and irritable as hell. Not a surgical candidate. 5 days of q1 neuros. Did we do them? Uh, no. Basically you end up deciding between fudging some charting and harming your patient

No doubt if you (or anyone else) had done q1hr neuro checks for five days you would have put your patient into a state of psychosis, perhaps even precipitating extreme HTN, hyperglycemia, and other physiological deterioration. Honest to god waking someone up hourly is essentially the protocol followed by the CIA when they are trying to "break" terrorists to get information it seriously probably qualifies as torture under the Geneva convention.

[whofan, ADN, BSN, RN]

I work in a newly formed Neuro ICU with a no one physician in charge, we have neurosurgeons, neurology and a medical team all writing orders and making care suggestions. We've had SAH patients on q1 full nihss for 21 days if they are having vasospasms, with multiple trips to CT once they become delirious, because they will no longer participate in the stroke scales because they are tired, frustration, and delirious. It seems like a fight to even get them at 4 hour break between 11p-4a, and that took the patient hitting a neurosurgeon cause he sternal rubbed them. Its chaos at best in our unit even after 2 years. At this point the few experienced nurses left have started doing our education and taking research to the physicians to try to force some consistency.

[boxofrain]

So, newbie (kinda) nurse here with a quick question...what's the point? If you woke me up every hour of every night, I'd be A&OX0 by the second night. If you wake someone out of REM sleep, you won't get any kind of accurate picture of their mental status. Sounds like CYA to me. At one floor during nursing school, we woke patients up every four hours for vitals...including the ones on tele! Where's the logic there?