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medical condition, delirium, and its relationship to the nursing profession. The paper is partially a literature review as well as a literary comparison. The Journal of Gerentologic Nursing defines delirium as "a syndrome characterized by the rapid onset and fluctuation of altered mental status, primarily involving the domains of attention and cognition." (Waszynski & Petrovic, 2008, 49) The material provided suggests that detection of delirium very early is important in the prognosis of the patient who experiences delirium. The American Journal of Critical Care (AJCC) states, "delirium is associated with higher mortality, prolonged ICU stay, and greater health care costs." (Devlin et al., 2008, 556) The articles to be examined make critical connections between the roles that nurses play in the diagnoses and treatments of delirium, but they each approach the subject from a different perspective. McCarthy, for example, focuses upon the various perspectives of nurses that impede the recognition of delirium. Inouye et al., as another example, put specific emphasis on a particular method of recognition of delirium.
Delirium is a condition that presents itself with extreme confusion. Delirium affects a patient's brain function causing deterioration with great acceleration. Delirium hits hard and it hits fast. Delirium is a condition that can be brought on by a physical or mental illness. Most instances of delirium are only temporary and the condition can be reversed or treated effectively. In fact, there are a number of physical conditions that can bring on delirium, especially procedures or conditions wherein the patient's brain has been deprived of oxygen or other substances. Inouye et al. explain briefly the significance of recognizing and treating delirium in the following statement:
Delirium is a common and serious problem for hospitalized older patients and is associated with substantial morbidity and mortality rates. Occurring in 14% to 56% of hospitalized older patients, delirium represents the most frequent complication of hospitalization for this group. Despite its importance, delirium is often underrecognized in the hospital setting. (Inouye et al., 2001, 2467)
It is a condition that goes rampantly unrecognized and untreated. This condition affects a significant portion of hospitalized elderly patients. It is a secondary condition that can prolong symptoms of other conditions as well as hinder proper recovery. It is a critical issue for nurses because they spend a great deal of time with patients and in a way are a first line of defense against it. Those who spend the most time with the patients are put in a stronger position to recognize delirium earlier on, which leads to the treatment and eradication of this serious condition.
The research issues in the McCarthy are the connections to the recognition of delirium by nurses in elderly patients, depending on the environment in which the patient receives treatment. McCarthy makes strong arguments regarding how perception and therefore treatment of delirium changes based on the kind of environment such as a clinical hospital or in the patient's home. She contends that the environment is an important factor that influences the philosophy of nurses regarding the detection of delirium.
Explanation for the differences among clinical reasoning patterns nurses use in the context of caring for older adults who demonstrate symptoms of confusion can be linked to the "over- arching philosophy" of aging that they embrace and operationalize in particular clinical situations. These overarching philosophies serve as perspectives that condition the ways in which nurses judge and ultimately deal with older patients experiencing acute confusion. (McCarthy, 2003, 204)
Devlin et al. (2008) as part of the research provided by the AJCC, developed a survey for RN's currently working in an adult ICU. The survey was given to only nurses who currently have delirium assessments in place at their hospital. The purpose of the survey was to determine the nurses' knowledge of the delirium assessment and the frequency in which the nurses actually use the assessment tool. The survey also compared the frequency in which the delirium assessment tool was used with the frequency in which the sedation assessment tool they have in place was used. The findings showed, the assessment of delirium was rarely done by the nurses surveyed. Inouye et al., have slightly different, yet similarly themed research issues. The research issues of their article are how crucial nurses are to the detection of delirium and yet how often it goes unrecognized by nurses. Their and the intent of Inouye et al. is to study how the detection of delirium by nurses is affected when the Confusion Assessment Method (CAM) is taught and implemented for their use.
Nurses are key to the early recognition of delirium, yet this study showed that when the CAM was rated by untrained nurses as part of routine clinical care and without any formal cognitive assessment, delirium was often unrecognized. Nurses were asked to rate the presence of delirium, as well as specific delirium features using the CAM. (Inouye et al., 2001, 2471)
McCarthy firmly asserts that part of the reason why delirium is so widespread is because nurses do not recognize it readily. The disproportionate lack of recognition is linked to the perceptions and philosophies of practicing nurses.
…nurses think that cognitive decline, although not regarded as an inevitable consequence of aging, still occurs with regularity among older patients. Unless they are or can be convinced that symptoms of confusion represent a change from a patient's normal baseline, they will remain uncertain about the clinical significance of the symptoms observed. This uncertainty prompts actions to either confirm or discount nurses' tentative impressions, thus delaying necessary evaluation and subsequent treatment of underlying and potentially life-threatening physical problems. (McCarthy, 2003, 205)
Nurses essentially believe that the symptoms of delirium are naturally a part of the aging process. When nurses believe that the patients should and will naturally be confused, disoriented, and suffer from rapid mood swings, then they will not recognize such symptoms as part of a medical condition such as delirium. They will simply perceive the symptoms as a natural part of life and a natural part of the kinds of behavior that they must deal with as part of their profession in nursing. Inouye et al. have a specific recommendation on how to improve this situation, which is the instruction and implementation of the CAM. (Inouye, 2001, 2472) They clearly agree that there needs to be improvements regarding perception and detection of delirium by nurses. Whereas in the McCarthy article the focus is on the perspective and the philosophy of nurses, the Inouye et al. article focuses on the observations of nurses that hinder diagnosis and treatment. The focus is on the improvement in the recognition of delirium. There is more clear information regarding the risk factors of delirium in addition to the promotion of better recognition techniques that nurses can use, such as the CAM.
Comparison of Themes
Ramaswamy et al. (2010) tackle the topic of assessment improvement, diagnosis improvement, and treatment improvement. Ramaswamy et al. (2010) is a vigorous study/experiment to improve and implement delirium early interventions with the assistance of nurses. For Schuurmans et al. (2001), the theme is to bring the knowledge of the average citizen to the knowledge of the nursing professional. The Schuurmans et al. (2001) piece is an overview of delirium providing definitions, vital statistics, risk factors, and the nurse's role. The theme of the McCarthy article is a nurse's philosophy on behavior and a type of patient (elderly) is an extremely important factor in a nurse's efficacy in recognizing and then treating delirium in older patients. Another theme of her article is that the environment in which the nurse and the patient are in is another very important factor in the recognition and treatment of delirium. For her, context is extremely important. In different contexts, a nurse's philosophy toward a patient alters. For Inouye et al., the themes present in their article is that nurses and patients benefit directly and greatly with a specific method for recognition of risk factors. They believe that cases of delirium would be greatly reduced if nurses were formally educated and prepared to recognize risk factors. They think there is a great deficit in the recognition of delirium not because of incompetency or insensitivity of nurses, but because of a lack of training and in way, lack of appropriate perception. Delvin et al. (2008) attempted to find out the extent of nurses' knowledge of assessment tools and how frequently such tools were used. Waszynski & Petrovic, (2008) also attempted to create, evaluate, and improve delirium assessment tools for nurses.
The articles express sincere concern in the recognition and treatment of delirium. Both articles stress the importance and significance of nurses in the fight against delirium. There is some overlap in the themes and research issues presented in each respective article, yet there is clear distinction in the priorities of the authors. Both articles have practical and reasonable goals and expectations of nurses. To improve the recognition and treatment of delirium, together, these articles advocate for nurses to challenge…[continue]
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