Delirium?

[GalRN]

OK, maybe this is a pet peeve, but curious...

Have you noticed the huge group of patients with delirium - do they get ignored in your facilities? By ignored I mean no one notices that there is something organic and reversible going on. Most nurses I meet think that it is something that you see in elderly pts with UTI's and think no furthur. I work registry and so I get to see multiple facilities and their lack of response. Part of it is the ER's fault. I'm not knocking the ones that do the tests they should and rule out everything obvious. A lot of them do only the tests required to get them out of the ER.

I had a pt last month- a 24 y/o with no previous psych hx, brought to the ER for a medical workup by family. He had been sluggish during the day and for 5 nights prior to coming into the hospital he had been hallucinating and stating that he could see ppl in his house, thought they were going to steal his guns. Very agitated. This was a sudden change. At the ER they did a CBC, BMP, UA, UDS. That was it. He became very psychotic and agitated, finally tried to head butt a sink and was put in restraints. This crisis unit was not equipped, we couldn't get accurate vitals. By the time the whole incident ( which included FD refusing to transfer him and leaving) was over, he made it to the ER and coded. He is still not conscious.

Another more recent case was in a woman around 30 y/o. She had been psychotic when she arrived but it was almost resolved. Apparently it evolved of a week's time. I had not cared for her but her uncle made a stink (thank god) and looking at prior notes this was not her baseline. She was trying to pick up things from the floor that were not there. She couldn't eat, too distracted, didn't even know what yr it was. It turned out to be cogentin toxicity.

Am I the only one who sees this as a growing problem that is not picked up by staff due to lack of knowledge? Or are the patients with delirium coming to the psych units more often?

[Davey Do]

Patients manifesting classic sx of psychosis, such as delirum, are often rubber stamped in ER as psych and passed over. Typically, on the Gero-Psych unit, a Patient admitted from the ER with "psychosis nos" has a uti.

I guess it's an easy-out mind-set sort of thing: "Pt acts weird. Pt must be psych." Job done. Rubber stamp: psych.

One thing we can do as Nurses is to be a stumbling block in the road for those who wish to rubber stamp Patients with suspicious test results.

[Whispera, MSN, RN]

Another thing I see often is: "patient acts wierd and is old-->patient is old and we don't need to worry about it."

And yet another thing: "patien acts wierd-->patient is psych-->let's put him where we don't see his behavior because he's just pretending and he's a pain in the neck and keeping us from taking care of real patients."

[GalRN]

I know exactly what you mean.... And it does happen all the time with older patients. I had been a nurse for at least 5 yrs when I got a job on a dementia unit. We had a new lady, from an acute care unit, still with a UTI resolving. I was floored when she complimented my shirt, I told her it was my favorite, and then she referred to it as my favorite shirt the next day. Doh!

Thing is, the cases of delirium I've seen lately weren't in anyone over 35. My lady with cogentin toxicity- she was 32, and the staff (who are very good) noticed that she was kinda incoherent, so the MD backed off on a bunch of her meds. When her uncle came in and totally tweaked I paid better attn. He wanted to know why she was worse. At that point, so did I. The notes clearly document a descent into total lala land over about a week. Even her uncle said she was med seeking. She was known to fake all kinds of symptoms- she liked thorazine. So they decided that she was playing a game for meds. Problem- when I gave her the AM meds, she didn't know what they were, then forgot about them, then dropped then, once we got em into her mouth she forgot to swallow them and gagged when they dissolved.

She was sooooo obviously seeing very clearly, stuff that was on the floor and appeared to be trying to get away from her.

It was just, THE LOOK. See it once and have it correctly identified, never miss it again.

The other most recent and most obvious is also the most enraging and tragic thing I've seen. And I've been a nurse for 13 yrs.

As above, 24 y/o male, no prior psych hx, no illegal drugs. Just bought a house with his girlfriend and was on unemployment but had a steady working history. Healthy, other than shoulder surgery 6 months ago. He had his circadian rhythm upside down, agitation and AH?VH at night with delusions. For 5 nights. His parents didn't think psych. They took him to the ER bc they thought maybe he had a neuro issue. But psychosis = crazy= not important get em outta here. He was at the facility for under 5 hrs. Went from polite, to stressed about the "ppl outside from back in high school", to running up and down the halls (accompanied by some very tired techs trying to avoid seclusion or restraint). He ended up in restraints. 7 points. And even after I'd given him 8mg IM ativan, at least 25mg IM haldol, 2 of cogentin, plus 50mg of benadryl, he was still bucking, and yelling and barely restrained. Then I noticed that his upper lip was twitching kinda regularly, which was NOT normal (relatively). The doc had been on the phone with me for an hour. She was really worried. Then he started having an overall twitch, about every 30 seconds. It just looked way too tonic clonic to ignore. Called 911, and per order of the doc, and my own nursing judgement, I gave him 10mg IM valium. And stood there with an ambu bag waiting. This kids brain was frying! We couldn't get vitals, due to his movement.

The FD showed up, laughed, and said they couldn't take him to the ER b/c they "weren't trained in restraints". Also seemed to think it was an act. The left us. 911 left. *** do you do when 911 leaves you??? I pointed out that his airway was not secure with all of the benzos, had kinda figured they could help with that.... Never would've given that amt of benzos in another situation, and without the FD on the way. The captain told me that as long as he was twitching he was breathing. That made me mad, but now it just makes me sad. After they left we called the county hospital to find who they used for transport. Called them. They understood, and sent a paramedic and RN. They scooped him, in our restraints and all. The 02 sat on the way to the ER was 39%. He flatlined twice in the ED. Last I heard he was still unconscious, and it's been a few months. He isn't coming back. The Phoenix FD cost him at least 30min of 02. The ER that didn't check anything cost him his life. We did everything we should've and more. I was very proud of the whole team. It went beautifully, except for the part about the pt.

They don't know what caused his delirium. Just that it was there.

Of note, during the whole episode, the ER who had sent him called with someone else to transfer. Suicide attempt- GSW to the abdomen - 5 HOURS PRIOR!! 2 holes, but they didn't know if it was entrance/exit or 2 bullets. H + H dropping. We were able to ignore that guy, usually we have to justify all refusals to the medicaid ppl. They give us half the record, not realizing that I will ask for a MAR if I see a med ordered and that telling me there isn't one just makes them reveal what idiots they think we are. GRRRR. Is this an AZ thing? I am from MA, and worked in CA too. Never saw this stuff.

I make an effort to broadcast it a non annoying manner that IF IT IS VISUAL, THINK ORGANIC!

I do mention quick onset, but am broad. Rule of thumb- if the patient hasn't been like this for a long long time, and there is no medical explanation, it is a medical emergency. And it is your job to either rule something in or make sure everything possible is ruled out. Even if you send them to the ER and they test for stupid stuff, it's a start, and a legal defense, really.