Tips for delirium behavior management

[CCU BSN RN]

I had a patient last night postop about 2 weeks from extensive cardiac surgery. Was on a lot of pain meds on a chronic basis pre-op, so naturally is on a lot of opiates. And benzodiazepines. And antipsychotics. Precedex worked pretty well but we're trying to get this guy ready to transfer to the floor someday, so we're trying to get him on some kind of plan that will facilitate that.

So this guy is AAOx1-2 depending on the moment, delusional, picking at his chest tubes, arterial line, central line, foley. Not tugging, but definitely too close for my comfort.

This guy keeps almost falling asleep mid sentence because he's so tired from being in ICU and constantly awake for days on end. And just as soon as he drifts off, he startles himself back awake, freaks out, and we're back to square one.

I know if he could just get some sleep, it would do wonders for his mental status (among other things). He's already on basically every drug I can give him without killing him (including Seroquel now, but also dilaudid, oxycodone, ativan)

I had some mild success by turning the lights out, putting my calm voice on, pulling up a chair, and very calmly and quietly answering his questions, and basically shushing him to sleep like I would to a toddler.

My question is, what are your hacks for getting the delirious/demented/AMS patient to:

1. stop touching/picking at lines

2. go the EFF to sleep

when they won't even understand that their call bell is not a hamburger or that you just gave them a sip of water 5 minutes ago.

[Meriwhen, ASN, BSN, MSN, RN]

Every psych nurse I have ever worked with has said never argue with delusional patients ... that goes for delusions due to medical issues as well as psych. I have found that it helps to keep my interactions concrete and directive and to either ignore or deflect delusional statements (i.e. "I'll see about the ice cream later, right now we have to clean you up/check your blood pressure/give you this medicine, etc.") Accept the fact that you cannot re-orient him ... continuing to try just wastes your time and aggravates him.

And did I mention stop giving him Ativan?

As a psych nurse, I agree with all of this. You can give the reorientation the old college try, but I wouldn't persist on trying to make the patient AO4 (or as close as you can get), every single time you enter the room. You shouldn't feed into the delusion (i.e., don't agree with the red box being full of Blue Bell) but look for the underlying message and see what you can do for it. "The red box on the wall doesn't have ice cream but I'll see if I can get you some. First I have to...". Just like Heron said.

Also, while Ativan and other benzos are often relied upon to snow aggressive patients, they can actually be activating/stimulating to a small percentage of the patient population. They do use Ativan to treat catatonia, after all :) And I see benzos frequently having this paradoxical affect in older patients. When benzos do that to a patient, we'll shelf them and use antipsychotics such as Haldol or Zyprexa to calm them down.

[CCU BSN RN]

Thanks to everyone for the great suggestions! I get so used to everyone being intubated/sedated sometimes that my skills in this area have taken a nosedive.

I also definitely needed to hear that it's okay to feed into their delusions a little bit instead of tirelessly reorienting and making their agitation worse.

[MunoRN, RN]

First of all, thank you to every one of you! Even those who weren't answering the question itself, you provided valid suggestions and food for thought.

To clarify some of the questions: This guy is in his mid 60's, has been on 40-60mg oxycodone IR q4h for years at home. That makes it tougher to avoid opiates because the opiate withdrawal itself could make him more confused and/or delirious, and I really don't need a miserable patient vomiting all over their sternal incision because they're basically withdrawing from heroin. There is definitely a huge case to be made for reducing use of opiates, benzos, anticholinergics when delirious. I think the rationale for the ativan was that this guy is absurdly strong and while he was a peach for me, he has been intermittently combative and come very close to injuring staff, so we have definitely been erring on the side of giving ativan when he starts to get angry or visually upset about something.

He did have restraints at times to prevent tube/line dislodgement but once he was extubated he would just scream constantly when restrained. He did have a sitter but it was discontinued because he would constantly talk (albeit pleasantly) and ask questions and it seemed like it was causing too much stimuli to have another person in the room with him constantly. Didn't help that she kept all the lights on, kept trying to re-orient him constantly even though it was absurdly ineffective, etc. I ended up being in the room twice as much when he had a sitter because she would call me in every time he touched his chest tube tubing or raised his voice, or she would let him have his call bell which he didn't understand how to use, then I would respond thinking it was her needing me, and she'd say 'oh yeah he's just going to push that button all night'. And I literally just couldn't even. The right sitter probably would've been a useful intervention, but the kind of sitters we were getting sent...

To address those of you who pointed at infection as a possible cause of this guy's delirium, yeah probably. He has been intermittently spiking fevers up to 101.9 for his entire postop course. We removed and replaced his lines to culture the tips, sent urine, sputum, and several sets of blood cultures over the course of several days. We sent his pleural fluid from an effusion for culture, his incisions don't look infected at all. Mild leukocytosis, WBC somewhere between 12 and 20. Infectious disease is consulted and basically want us to CT scan his chest/abdomen/pelvis to look for some other infectious source, but getting him to behave long enough to be scanned has been a tricky mistress.

Sodium was 155 when I picked him up. Gave IVF and encouraged PO fluids and was trending down by end of shift

ABG was normal

Glucose was right around 180-240

Wearing him out during the day to establish sleep/wake schedule is also an awesome suggestion, but made more difficult by the fact that this guy has basically not been out of bed in 2 weeks. Normally totally unheard of, but combo platter of hemodynamic instability, prolonged intubation and heavy sedation (every time we lightened sedation he would flip out, get agitated, breathe over the vent, not follow directions, etc. but the doses of sedation/pain meds needed to keep him calm were causing such respiratory distress that he actually got re-intubated a few times in his first few postop days). Anyway, he was already constantly moving around in bed, but now he's so deconditioned that it's going to be a long road to get him back to ambulatory. Agree he could probably be hoyered to a chair at least.

Normally I'm all about getting to the cause of the delirium so we can fix that, but in this case the equation simply has too many variables. Infection, prolonged ICU stay, sleep deprivation, lyte imbalances, high dose narcotics...well, they certainly complicate the clinical picture.

Now that we've discussed a bit, I have a follow up question.

When you go in the room to provide care, give meds, etc. and the delirious patient is coming at you with some ridiculous claim/version of reality, for example "Why won't you just give me the ice cream that's inside of that red box on the wall?", how exactly is one supposed to respond to that?

Things I've tried:

1. "That's a sharps bin. It's full of discarded needles. There is no ice cream in it." Then he got indignant and started accusing me of lying and saying he would get OOB and get the ice cream himself.

2. "We're all out of ice cream. Dietary will bring more in the morning" Then he started telling me which store I should go to to buy him some ice cream with the implication being that it wouldn't be out of the realm of possibility for me to stop caring for my assignment, leave the premises, find somewhere open at 3am, and buy him ice cream.

3. "You're diabetic and on an insulin drip. Your doctor says you can't have ice cream right now." Then he got indignant and started telling me that I was lying, the doctor said he should have ice cream.

4. Silence. Ignore the comment. He looks at me like I'm dumb and then starts accusing me of ignoring him.

5. "I'm going to the store to get you some ice cream, but you need to stay here in bed and leave all your lines, oxygen, etc. alone while I go. Every time you take something off I have to hightail it back here, and it will take much longer to go buy ice cream if you're not behaving." This worked until his goldfish memory reset itself, so 2 minutes max.

Basically I just feel like I can't win with patients like this. I feel like I have no idea what to say to them, reorientation doesn't work, they have no short term memory, no logic/sense. It seems like no matter what I say, I wind up exasperated, the patient winds up agitated or loud or attempting OOB. Nobody wins.

So, let's hear it. Who has things that they say to delirious patients that buy them some time to go care for other patients?

I get the desire to give him Ativan when he starts to get out of hand, but I would suggest using Haldol in these instances instead, think of Seroquel, xyprexa, valproic acid etc has basal delirium control, with Haldol for breakthrough agitation. It's important to give appropriate doses as well, some docs prefer to order 0.5-1mg, which essentially just homeopathic, our current protocol is to start with 2mg and double it every 15 minutes up to 8mg at a time to achieve desired effect.

Unlike benzos which have been shown to consistently worsen delirium, opiates are still appropriate to use in delirium and actually the worse thing you can do is give too little analgesia. There was a time when we thought opiates should be used sparingly in delirium, because correlation between opiates and delirium was found, but as it turns out this more likely represented pain as a causative factor in delirium, as a result current recommendations are to make sure pain is being thoroughly treated in patients with delirium as pain is a major drive of the sympathetic overstimulation that contributes to delirium.

As for activity, the ideal setup would be one of those rolling things you put toddlers in, where they sit in a seat that is supported on wheels so that they can touch the ground and sort of walk but can't fall down. Unfortunately they don't make such a thing for adults, but you can sort of approximate it with a cardiac walker and wheelchair pushed right up to the back of it. The can't fall forward or to the sides, falling back just means their sitting in the wheelchair, if they start to buckle and go straight down, missing the chair, then you just grab their gate belt and pull their hips back into the chair as they go down. Letting them "swim" in bed also works, but is hard to do when they've still got an art line, chest tubes, etc.

Reorienting often doesn't work with these patients, to them you're just being confrontational which then makes them agitated and combative. Redirection tends to work much better. If the patient is obsessed with ice cream then use that to occupy them, get them talking about ice cream; how it's made, what kinds they like, don't like, etc

[Penelope_Pitstop, BSN, RN]

I suggested googling "BEERS Criteria 2017" and printing out the pocket guide. There are things on there you would never think of that could cause delirium. I know it's intended for older patients but I find it works for anyone at risk.

When I first heard of Haldol as a recommendation, I thought it was nuts but you know what? It works especially for ICU delirium wherein one can't remove the offending agent. For those with QTc issues, Seroquel was the go-to (super small dose).

There was a delirium assessment protocol that I used frequently in MedSurg. If you suspected that was happening, you did vitals, an accucheck and a bladder scan, removed any "extra" medical equipment and contacted the provider for orders (suggested orders were for pan-culturing and fluids, as well as changing meds that met BEERS criteria). Sometimes yanking a Foley that wasn't really needed or seeing if a heart monitor could be discontinued in someone who'd been NSR for 24 hours could make all of the difference.

I know in the ICU that isn't as easy, though. One thing we did was try to encourage the difference between night and day. Move the bed to face the window, get the patient out of bed and into a geri-chair (even intubated patients!), put on TV during the day ONLY, etc. We also had a "sleep protocol" that allowed us to "skip a turn" in the middle of the night if the patient's skin was okay. And we used as little sedation as possible and rarely, rarely used restraints (mitts were allowed if needed). We even walked our stronger vented population during the day with the help of PT.

[amoLucia]

To Munro - The adult size 'roller' seat thing exists and is called 'geri walker'. (I have seen it called a merry walker.)

They are nice things but have fallen out of favor in many NHs because the 'seated' pts were rolling into other pts and causing them injuries. The 'seated' confused pt already has a poor safety awareness and the rollers required a sense of spatial orientation to navigate. And they were rather big making it all the harder to safely move around on corridors.

When they first came out, I loved them. Until I got tired of making out so many incidents reports for injuries. Including one spectacular head-over-heels, topsy-turvey tumble.

To CCU BSN - It is a common care-plan intervention of 'therapeutic fibbing' on many of LTC's dementia pts. Used for those pts for whom Reality Orientation only causes more confusion, agitation or violence.

Why use RO when all it does is cause more 'psychic distress' for the pt? There's been some other postings here about using it.

[MunoRN, RN]

http://www.toysrus.com.au/www/732/files/704318_steelcraft-jetta-baby-walker.jpg[ATTACH=CONFIG]24453[/ATTACH]

To Munro - The adult size 'roller' seat thing exists and is called 'geri walker'. (I have seen it called a merry walker.)

They are nice things but have fallen out of favor in many NHs because the 'seated' pts were rolling into other pts and causing them injuries. The 'seated' confused pt already has a poor safety awareness and the rollers required a sense of spatial orientation to navigate. And they were rather big making it all the harder to safely move around on corridors.

When they first came out, I loved them. Until I got tired of making out so many incidents reports for injuries. Including one spectacular head-over-heels, topsy-turvey tumble.

That's pretty close, but I can't find one with that's basically a seating sling on wheels, I was thinking more like this, including the toys to play with:

[amoLucia]

I've never seen anything like that. I don't know that they even make anything like it for adults. The 'geri walker' that we used to have did have wheels.

I wonder if Rehab/PT/OT might have something similar for supporting ambulation training??

They make things for everything today!

[CoffeeRTC, BSN, RN]

I have 3-4 of these type of patients in my SNF right now. Very frustrating.

[Wolfbiologist]

One thing to keep in mind (my brother was very sick in ICU last year), I have seen this scenario from the family perspective and knew the patient as well as a brother can.

The delirium is not the patient's fault. It's yours. By you, I mean the ICU itself. My brother was a completely reasonable, calm, sane, and bright person before the ICU. After 3 weeks of sedation, pain meds... etc, he behaved like the patient in the OP. Finally they stopped the drugs (as suggested by many responses) than caused much of the problem. He did have a UTI from the foley and when that was addressed, a lot of the delirium dissipated. He was in far less pain and could sleep.

He came home physically well but his ICU induced PTSD has kept him from functioning well at work. He isn't the same guy.

I saw a dedicated nursing staff that made him well BUT lacked some compassion. Comments were made to me suggesting his delirium was a defect of his biology rather than his treatment. Nurses were frustrated with HIM rather than the care plan for him.

Be patient with your delirious patient. They need your compassion and your creative approaches to getting those nasty chemicals out of their bodies. Help them sleep naturally, protect their dignity, and find the cause of those damned infections.

[CCU BSN RN]

Thanks to all for the suggestions/toughts

We usually lean away from Ativan as well, but I apparently forgot to mention the ETOH withdrawal we were initially trying to treat during his first week postop. So narcs and precedex and/or ativan were kind of necessary evils to prevent acute ETOH and opiate withdrawal in his immediate post op period.

Chest tubes stayed in forever for high outputs (not bleeding but copious serous drainage) and I personally walked in on him with wrist restraints on, contorted into a ridiculous position double fisting his CTs. I added mitts. He started spitting. Added a mask at times. Needed 4 staff to pry his death grip from his tubes one night.

He was on seroquel per psych which sometimes got me an hour, but he had an NGT for an ileus for a good while, then kept failing swallow evals.

Just feels like a big no-win scenario when you can't get a sitter and then have to admit a dissection next door. When they're your only patient it's emotionally exhausting, sure, but at least they're relatively safe. When another pt gets thrown into the mix it'd be nice to have a way to keep both of them safe so I don't have to feel like I have to choose who can get safe care.