PSYCHIATRIC NURSING

What is known on this subject? • Delirium prevention and effective management require pharmacological interventions as well as non-pharmacological methods. Non-pharmacological methods could be performed independently by nurses to provide improvements in patient care. What is the contribution of this paper? • Current review integrates the nursing process with the use of non-pharmacological approaches based on randomized controlled trials and clinical guidelines. What is its contribution to the practice? • This review contributes to the approaches and discussion for delirium management in line with the nursing process and improves evidencebased care. 138 Psikiyatri Hemşireliği Dergisi Journal of Psychiatric Nursing increased, dementia increased, and nosocomial infection and their need for long-term care increased. [8,9] The National Institute for Health and Care Excellence (NICE) guidelines emphasize that patients who have risk factors for delirium development should be assessed for delirium within the first 24 hour of admission. [2] This fluctuating situation should be monitored by nurses and diagnosed with rapid intervention by health care providers. [2,3,6] Using pharmacological agents in delirium management is beneficial when treating this acute situation but is not sufficient in preventing delirium. Additionally, medication can cause cardiac dysrhythmia, increase in drowsiness, and side effects such as stroke in dementia patients. [10,11] NICE guidelines suggest the short-term use of pharmacological agents (for one week or less) on agitated patients carrying the risk of hurting themselves and others and for whom communication techniques are insufficient. [2,12] Therefore, non-pharmacological interventions should be used to prevent and manage delirium. This review study aims to combine the non-pharmacological interventions, indicated for the prevention and improvement of delirium based on clinical studies and available guidelines, with the nursing care process and contribute to evidenced-based care. Non-Pharmacological Approaches in Delirium Management The management of delirium includes the prevention of delirium as a first step. Following the diagnoses of delirium, the next step is determination and elimination of the underlying causes, then treatment and prevention of delirium and the complications. [2] Primary non-pharmacological interventions that can be initiated to prevent and manage delirium are as follows: re-orientation, decreasing environmental stimuli, early and frequent mobilization, providing hydration and sleep hygiene. [2,13] A systematical review study stated that administrating non-pharmacological methods decreased the risk and duration of delirium in intensive care units. [14] Nonpharmacological interventions used in delirium management are examined below. The scope of cognitive interventions includes providing the reorientation of the patient and administrating suitable cognitive stimuli. Colombo et al.[15] administered cognitive stimulus protocol on patients in their study. This protocol includes addressing the patient by name and giving them information about the name of the hospital, current service and prognosis of the disease. The protocol also includes decreasing the noise and light levels during night, verbal and visual stimuli such as providing a clock and a newspaper at the bedside, and reorientation. This prospective observational study found that the re-orientation is effective in preventing delirium and is an easily applicable intervention. [15] Studies on cognitive interventions and delirium mostly included multiple non-pharmacological interventions[16,17] and therefore, limited number of studies were available. The scope of providing environmental characteristics includes lighting, noise management, using calendar and clocks, explaining the equipment (pictures, decoration, materials, alarms, paging system etc.) that are present in the patient environment. [18] A study by Taguchi et al.[19] stated that the radiant light therapy decreased the delirium development in patients receiving treatment in geriatric care units. A randomized controlled study which examined the effect of noise level on sleep quality and delirium development in patients in the intensive care unit found that the rate of delirium development decreased as the noise level decreased. The same study found that using ear plugs may decrease the delirium risk to 53%. [20] Another study conducted with 272 elderly people in a nursing home reported that the severity of delirium might have been decreased by providing glasses, hearing aids, and personal belongings in their environment. [21] Also, intervenTable 1. I WATCH DEATH: The most common causes of delirium Etiology Types of cases in clinical environment Infection Pneumonia, urinary system infection, encephalitis, meningitis, syphilis Withdrawal Alcohol, sedative-hypnotics Acute Metabolic Conditions Acidosis, alkalosis, electrolyte imbalance, liver or kidney failure Trauma heat stroke, burns, surgical interventions Central nervous system’s pathologies Apse, tumor, bleeding, crisis, stroke, vasculitis, normal pressure hydrocephalus Hypoxia Hypotension, pulmonary embolism, pulmonary or cardiac deficiencies, anemia, carbon monoxide poisoning Deficiencies B12 vitamin, niacin, thiamine Endocrinopathies Hypo-/hyperglycemia, hypo-/hyperadrenalism, hypo-/ hyperthyroidism, hypo-/ hyperparathyroidism Acute vascular problems Hypertensive encephalopathy, shock Toxins Drugs, drug abuse, pesticides, chemical solvents Heavy metals Lead, manganese, mercury Irwin R, Rippe JM. (2014). Irwin and Rippe’s Intensive Care Medicine (Tr. Edi. Tulunay M, Cuhruk H). Ankara: Güneş Kitabevleri, 6th Printing Volume 2 (Original publishing date 2008). 139 Canan Karadaş, Nursing approaches in delirium / dx.doi. org/10.14744/phd.2019. 81994 tions such as preventing malnutrition, minimizing physical restraints, covering catheters, providing sufficient lighting, minimizing the noise level, providing pain management, and monitoring the medication used in terms of delirium development are recommended. [22,23] Providing physiological support includes maintaining fluidelectrolyte balance, nutrition, body temperature, natural excretion type, oxygenation and blood sugar control, blood pressure regulation and infection control of the patient. [24] Morita et al.[25] stated that hydration and pain management decreased the incidence of delirium. Davies et al.[26] reported that hydration was important for patients in the terminal period of cancer; however, there was no intergroup difference in terms of delirium. Similarly, the retrospective cohort study of Krishna et al.[27] which was conducted with 238 patients stated that hydration maintained in the last 48 hours of life did not have an effect on delirium or survival. In parallel, previous studies on hydration reported the effect of hydration on delirium differs based on the characteristics of the patient population, severity of dehydration, and the timing and hydration methods (oral, enteral, parenteral). Therefore, providing sufficient hydration may have potential positive effects on the prevention of negative health outcomes including delirium as long as no contraindication is present. Providing early mobility includes administration of programs starting from passive range of motion exercises in bed to independent walking based on the toleration level of the patient. [2,18] A randomized controlled study by Schweickert et al.[16] found that mobility significantly decreased the number of days the patient experienced delirium. A study by Needham et al.[28] initiated physical therapy on patients based on their toleration levels and found this decreased the incidence of delirium from 53% to 21%. Balas et al.[29] used the ABCDE bundle (ABC: Airway-Breathing Coordination, D: Delirium Monitoring and Management, E: Early Mobility) which included episodic sedation and delirium monitoring and early mobility which decreased the incidence of delirium approximately by half. A study conducted with patients aged 65 and older in intensive care units examined the effect of range of motions exercises on the prevention of delirium and found that the incidence of delirium decreased two and a half times more in the intervention group than the control group. [30] As opposed to these studies, a study which examined the effect of an exercise program and re-orientation processes on patients and found that these interventions did not decrease the incidence of delirium. [31] However, in this study delirium assessment was performed only once every 48 hours, therefore, the results are not reliable for this study. Studies in the literature show differing results regarding the effects of mobility on delirium. Therefore, more randomized controlled studies should be carried out to determine the effectiveness of content, duration, intensity and frequency of the mobility programs on the prevention of delirium. In studies examining the non-pharmacological methods one by one, positive results regarding the prevention of delirium can be seen. However, studies in the literature recommend that non-pharmacological interventions be used together. [14,32] A study which used the established multi-component non-pharmacological interventions found that the duration of hospital stays of elderly patients in the internal medicine services decreased as well as the delirium percentage and antipsychotic drug use. [33] A study conducted to prevent delirium after surgery found the delirium development rate as 4.9% in the intervention group on which multi-component non-pharmacological interventions were used by nurses while this rate was 20.8% in the control group. [34] Whether one non-pharmacological intervention used to prevent delirium is more effective and valuable than another one is not proven according to results of the studies conducted. The Nursing Process in Delirium Management The delirium diagnosis and management re