Management Decision for Post-operative Delirium

Description of the problem and proposed course of action.

Following the scenario mentioned in the appendix, my decision would be to outline the key issue considered to be the post-operative delirium or acute onset confusion that Mr. H is facing. His symptoms include hallucination like appearance of flash light around him which is a new finding. My priority would be to find out the relevant issue for the delirium and then to make decision. As the patient had catheter inserted, there is a high chance that he has grown bacterial urinary tract infection (UTI) and this could be the reason for his delirium. The pain induced delirium which is one of the major problem. The secondary reason for delirium may be due to the intravenous supply of morphine via Patient Controlled Analgesia (PCA) pump. I decided after all these observations that checking of urine culture is needed to confirm the UTI. Following that I need to thoroughly review the pain management techniques to minimise the pain. I may also consult with the doctor and the nurse in charge regarding the morphine administration.

Linking the decision(s) to evidence

Delirium sometimes known as ‘acute confusion’ it is sudden onset of mental confusion, disturbed consciousness, disturbed cognitive function and or perception, develops over 24-48 hours, it is associated with a reversible medical, surgical or pharmacological insult to the person ("Sudden confusion (delirium)", 2018). For the evidence to support my decision, first thing is to check the causes of delirium having relevance with the current case under consideration. According to medical reports, the major causes of delirium are, infections (e.g. UTI and pneumonia), pain due to injury/operation, imbalance in neuro-transmission and sometimes due to medications. As stated earlier the patient had catheter inserted ,sometimes inside the catheter wall there is a high chance that under hydrated condition a biofilm can form of bacterial growth leading to UTI (Nicolle, 2014). Mayne et al in a systemic review assessed the delirium associated with UTI in case of elderly persons (Mayne, et al, 2019). Eide et al, have clearly demonstrated cohort study of delirium due to UTI caused by the renal catheter (Eide, et al, 2018). From these secondary research evidences I concluded that the use of catheter during the operation can be a major contributing factor towards the delirium, Therefore, I decided to do a urine culture of the patient to confirm UTI.

Post-operative delirium is an acute problem where brain dysfunction happens due to post-surgical trauma. This kind of disorder includes disorder in cognition, attention and low level of consciousness. Illusion is another feature of delirium and it has been found that for elderly patient this delirium is very much frequent (Kalish, et al, 2014). According to Steiner, post-operative delirium since last two decades become an important issue because 10-70% of older patients above the age of 65 years are those who undertake surgery face post-operative delirium. The reasons of this kind of delirium are septic shock (Steiner, 2011). As stated in the appendix morphine was administrated. Mu et al, have discussed that high dose of opioids used during post-operative pain management increases the risk of delirium (Mu, et al, 2017). Therefore, keeping this in mind I decided to discuss with a doctor regarding this matter. Post-operative pain is a huge problem for elderly patient, high level of pain can trigger abnormal behaviour in patients. For elderly patient these problems leads to delirium and without right pain management this delirium can increased at time. In the scenario it has been stated that the patient is reluctant to take medicine and may be due to that reason he disconnected the PCA device. Therefore I decided to use appropriate pain management.

Discuss the barriers and enablers for the decision(s) you recommend

The patient is experiencing hallucination and does not have a full understanding of his needs, moreover, he does not want to ask the nurses for anything because he thinks it is obligatory to ask the busy nurses for help. As mentioned in scenario he does not like to take medication. The patient do not want to communicate with nursse to take medicine, and therefore as a nurse probably solely my concern may not be enough in this case. I think these problems can be prevented by discussing with his wife and if possible then a psychological counselor can be consulted. This process can enhance the self-care concern of Mr H to use the devices like- PCA.

The positive side of the case is that, the delirium of Mr H is not extended to a fatal end. However, after the thorough check up and treatment of UTI, the patient need to be checked again if he have any delusion or cognitive disorder left.

Mrs H, wife of Mr H can be very much helpful. Properly training her with good communicational tools can help Mr H’s care giving a better dimension. Eventually, his food habits will also be better.

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References:

Eide, L.S., Ranhoff, A.H., Lauck, S., Fridlund, B., Haaverstad, R., Hufthammer, K.O., Kuiper, K.K., Nordrehaug, J.E. and Norekvål, T.M., 2018. Indwelling urinary catheters, aortic valve treatment and delirium: a prospective cohort study. BMJ open, 8(11), p.e021708.

Han, J. Shintani, A. Eden, S. Morandi, A. Solberg, L. Schnelle, J. Dittus. Storrow, A. Wesley Ely, E. (2010) Delirium in the Emergency Department: an Independent Predictor of Death Within Six Months. Annals of Emergency Medicine. 56(3), 244-252.

Healthcare Improvement Scotland in collaboration with the Scottish Delirium Association, NHS Education for Scotland and colleagues across NHS Scotland (2014) Improving the care for older people: Delirium toolkit. Improving the care for older people: Delirium toolkit. Healthcare Improvement Scotland.

Kalish, V, Gillham, J, and Unwin, B. (2014) Delirium in Older Persons: Evaluation and Management. American Family Physician. 90(3), 150-158.

Mu, D.L., Zhang, D.Z., Wang, D.X., Wang, G., Li, C.J., Meng, Z.T., Li, Y.W., Liu, C. and Li, X.Y., 2017. Parecoxib supplementation to morphine analgesia decreases incidence of delirium in elderly patients after hip or knee replacement surgery: a randomized controlled trial. Anesthesia & Analgesia, 124(6), pp.1992-2000.

Nicolle, L.E., 2014. Catheter associated urinary tract infections. Antimicrobial resistance and infection control, 3(1), p.23.

Sharon K. Inouye, Rudi G. J. Westendorp, and Jane S. Saczynski (2014) Delirium in elderly people. Lancet. 383(9920), 911-922.

Steiner, L.A., 2011. Postoperative delirium. Part 1: pathophysiology and risk factors. European Journal of Anaesthesiology (EJA), 28(9), pp.628-636

Scenario:

Mr H is 76 years old and lives at home with his wife, they have been married for 40 years and have two older children aged 43 and 40. He is generally fit and healthy and enjoys walking holidays with his wife. Mr H was admitted following a fall at home and brought to A&E via a 999 call to the ambulance service. He had an x-ray of his right leg taken on admission which confirmed a right femoral neck fracture, he had a cemented hemi-arthroplasty of the hip performed 24 hours ago and has been back on the Orthopaedic Ward since. Mr H had a catheter inserted in theatre which is draining well. He is eating and drinking small amounts only.

Since returning to the ward his observations have been stable, he has been prescribed paracetamol 1g every 6 hours and Morphine via a Patient Controlled Analgesia pump (PCA). He is also receiving low molecular weight heparin prophylaxis following surgery. The Physiotherapist is hoping to get Mr H out of bed today for the first time since the operation.

When Mrs H visits she asks to speak with the nurse and reports that she is concerned that her husband is becoming confused and is hallucinating, reporting that he can see flashes of light all around him. This is new behaviour for her husband and is totally out of character, it has been increasing with frequency since she arrived. Mrs H reports that her husband does not like taking medication and is a very proud man, he is reluctant to use the PCA and she has only seen him use it once since she arrived 3 hours ago. He does not want to ask the nurses for anything because he can see how busy they all are rushing around answering bells.