Risk factors and assessment of patient with intensive

RISK FACTORS AND ASSESSMENT OF
PATIENT WITH INTENSIVE CARE UNIT
PSYCHOSIS
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
1
mathewvmaths@yahoo.co.in

INTRODUCTION
In 1966, McKegney coined the term "intensive care
syndrome" to describe the 'madness'
increasingly encountered in patients in
cardiovascular recovery rooms, coronary care units,
chronic dialysis facilities and other intensive
treatment programs.
McKegney emphasized the importance of the
treatment setting in causing, preventing and
treating such syndromes
2

DEFINITION -ICU SYNDROME
Eisendrath defined "ICU Syndrome" as an acute
organic brain syndrome involving impaired
intellectual functioning and occurring in patients
treated within a critical care unit. "ICU psychosis"
was present when the impairment prevented the
patient from accurately judging reality
3

INCIDENCE
 Almost 40% of patient who admitted in ICU may
have ICU psychosis and their severe symptoms.
4

CAUSES OF ICU PSYCHOSIS
Environmental
Causes
Medical Causes
5

ENVIRONMENTAL CAUSES
Sensory deprivation
Sleep disturbance and deprivation
Stress
Continuous light levels
Lack of orientation
Medical monitoring
6

MEDICAL CAUSES
 Critical illness
(Respiratory disorder)
 Pain not be adequately
controlled in ICU
 Medication (drug)
reaction or side effects
 Infection creating fever
and toxins in the body
 Metabolic disturbances
 Heart failure (inadequate
cardiac output)
 Cumulative analgesia
 Dehydration
 Withdrawal from alcohol
or hypnotics
 Acute cerebral disorder
such as edema or stroke
 Hemodynamic
disturbance
 Nutritional and vitamin
deficiency
7

RISK FACTORS
 Baseline dementia
 Medications
 Advanced age
 Dehydration
 Depression
 Acute infection
 Sepsis
 Injury severity
 Seizures
 Head trauma
 Chronic illness (ie,
Hyperthermia
hypertension)
 Tobacco,alcohol use
 Withdrawal syndromes
 Visual,hearing
impairment
 Metabolic disturbances
 ApoE4 polymorphism
8

CLINICAL FEATURES
 Extreme excitement
 Disorientation
 Anxiety
 Agitation
 Restlessness
 Delusions
 Hearing voices
 Abnormal behavior
 Clouding of
consciousness
 Fluctuating level of
consciousness which
include aggressive or
passive behavior
 Hallucinations
 Nightmares
 Paranoia
9

ASSESSMENT OF ICU PSYCHOSIS
Intensive Care
Delirium
Screening
Checklist (ICDSC)
The Confusion
Assessment
Method for ICU
(CAM-ICU) tool
10

INTENSIVE CARE DELIRIUM SCREENING
CHECKLIST (ICDSC)
 Give a score of “1” to each of the 8 items below if
the patient clearly meets the criteria defined in the
scoring instructions.
 Give a score of “0” if there is no manifestation or
unable to score. If the patient scores >4, notify the
physician
11

N
o
Assessment Scoring Instructions
1 Altered
Level of
Consciousn
ess
 Score “0” if patient is calm, cooperative, interacts with
environment without prompting
 Score “1” if patient only interacts or responds when
stimulated by light touch or voice – no spontaneous
interaction or movement
2 Inattention Score “1” for any of the following:
 Difficulty following conversation or instructions
 Easily distracted by external stimuli
 Difficulty in shifting focuses
3 Disorientati
on
Score “1” for any obvious mistake in person, place or time
4 Hallucinatio
n/
delusions/
psychosis
Score “1” for any one of the following:
 Unequivocal manifestation of hallucinations or of behavior
probably due to hallucinations (e.g.catching non-existent
object)
 Delusions
 Gross impairment in reality testing
12

No Assessme
nt
Scoring Instructions
5 Psychomotor
agitation or
retardation
Score “1” for any of the following:
 Hyperactivity requiring additional sedatives or
restraints in order to control potential
dangerousness (e.g. pulling out IV lines, hitting
staff)
 Hypoactivity or clinically noticeable
psychomotor slowing. Differs from depression
by fluctuation in consciousness and inattention
6 Inappropriate
speech or
mood
Score “1” for any of the following (score 0 if
unable to assess):
 Inappropriate, disorganized or incoherent
speech.
 Inappropriate display of emotion related to
events or situation
7 Sleep
wake/cycle
disturbance
Score “1” for any of the following:
 Sleeping less than 4 hours or waking frequently
at night (do not consider wakefulness initiated
by medical staff or loud environment).
 Sleeping during most of day.
13

CAM-ICU TOOL
 The Confusion Assessment Method for ICU
(CAM-ICU) tool will be used for assessing delirium
in the ICU patients.
 The Confusion Assessment Method (CAM) was
created in 1990, and it was intended to be a
bedside assessment tool to assess for ICU
Psychosis /delirium.
 The CAM-ICU is an adaptation of this tool for use in
ICU patients (e.g., critically ill patients on and off
the ventilator who are largely unable to talk) is
defined in terms of four diagnostic features, and is
deemed present when a patient has positive
Feature 1 and Feature 2 and either Feature 3 or 4. 14

CAM-ICU TOOL
15

RASS (RICHMOND AGITATION SEDATION SCALE.)
17

MANAGEMENT
General principles
 Prevention of delirium and psychosis is must essential.
 Morbidity and death can be decrease by early detection
and treatment.
 The patient, his disorder, his family, the ICU staff, the
primary physician, the treatments and the environment
all must be considered for optimal management.
 Therapeutic endeavors do not stop with ICU discharge.
 A trusting relationship with the primary physician
facilitates all the above and is central to post-discharge
management.
20

PRE-ICU PREVENTION
 If ICU admission is elective, identify and treat
predisposing factors if possible. The ICU staff should be
alerted to these risk factors and to the current
therapeutic regimen.
 Decrease surgical organic precipitating factors.
 Diminish facilitating factors by careful preparation of the
patient and family.
 Planned interventions and possible adverse effects,
particularly delirium, should be described.
 A visit to the ICU and a meeting with the staff who will be
involved help to orient the patient and establish a
working alliance.
 Very anxious or obviously fearful patients stand to
benefit most from this approach. 21

ICU PREVENTION AND TREATMENT
 Using more liberal visiting policies
 Providing proper sleep
 Protecting the patient from unnecessary excitement
 Minimizing shift changes in the nursing staff caring
for a patient
 Orienting the patient
 Explain all procedure before doing
 Clear patient doubt
 Collect history from patient relative
 Even coordinating the lighting with the normal day-
night cycle
22

STAFF/PATIENT RELATIONSHIPS
Respectful
approach
Improve orientation
Build trust
Proper
communication
Autonomy in self-
care 23

EARLY RECOGNITION OF DELIRIUM AND PSYCHOSIS
Observe
for
attention
span
24

FACILITATING FACTORS
• Trustful relation
• Provide adequate information
• Encourage for normal sleep
• Provide calm and quite environment
• Avoid extra voice and unnecessary machinery
• Provide normal sensory environment: Windows, natural lighting and
night light
• Provide privacy
• Proper mobilization
• Allow to ventilate his feeling
• Pain management 25

PATIENT/FAMILY COUNSELING
 Reinforces patient's and family's strengths
 Promotes reality testing
 Reassures, encourages optimism
 Accepts adaptive denial and acknowledges
feelings.
27

ICU DISCHARGE AND FOLLOW UP
 Proper preparation for discharge
 Individual and family counseling
 Take medicine on regular time
 Proper follow up
28

RESEARCH ARTICLE
 Title :Risk factors for delirium in intensive care
patients: a prospective cohort study
 Authors:Bart Van Rompaey, Monique M
Elseviers,Marieke J Schuurmans, Lillie M
Shortridge-Baggett,Steven Truijen, and Leo
Bossaert
 Published online 2009 May
20. doi: 10.1186/cc7892, Crit Care. 2009; 13(3):
R77.
29

RESEARCH ARTICLE
 It’s a multicenter study at one university hospital,
two community hospitals and one private hospital
 All consecutive newly admitted adult patients
were screened and included when reaching a
Glasgow Coma Scale greater than 10.
 NEECHAM (Neelon and Champagne) Confusion
Scale.
 Risk factors covered four domains: patient
characteristics, chronic pathology, acute illness and
environmental factors.
30

RESEARCH ARTICLE
 A total population of 523 patients was screened for
delirium
 The overall delirium incidence was 30%.
 Age was not a significant risk factor.
 Intensive smoking , daily use of more than three units of
alcohol and living alone at home
 In the domain of chronic pathology a pre-existing
cognitive impairment was an important risk factor
 In the domain of factors related to acute illness the use
of drains, tubes and catheters, acute illness scores, the
use of psychoactive medication, a preceding period of
sedation, coma or mechanical ventilation 31

RESEARCH ARTICLE
Environmental risk factors were
 isolation ,
 the absence of visit ,
 the absence of visible daylight ,
 a transfer from another ward ,
 and the use of physical restraints
32

 Title:A comparison of the CAM-ICU and the
NEECHAM Confusion Scale in intensive care
delirium assessment: an observational study in
non-intubated patients.
 Author :Van Rompaey B1, Schuurmans
MJ, Shortridge-Baggett LM, Truijen S, Elseviers
M, Bossaert L(1University of Antwerp, Faculty of
Medicine, Division of Nursing Science and
Midwifery, Belgium, Universiteitsplein 1, 2610
Wilrijk, Belgium. bart.vanrompaey@ua.ac.be)
 Published on Crit Care. 2008;12(1):R16. doi:
10.1186/cc6790. Epub 2008 Feb 18. 33

 sample of 172 non-intubated patients in a mixed
ICU was assessed after a stay in the ICU for at
least 24 hours.
 All adult patients with a Glasgow Coma Scale score
of greater than 9 were included. A nurse researcher
simultaneously assessed both scales once daily in
the morning.
 A total of 599 paired observations were made.
34

RESULTS:
 The CAM-ICU showed a 19.8% incidence of
delirium.
 The NEECHAM scale detected incidence rates of
20.3% for delirious, 24.4% for confused, 29.7% for
at risk, and 25.6% for normal patients.
 The majority of the positive CAM-ICU patients
were detected by the NEECHAM scale.
The sensitivity of the NEECHAM scale was 87%
and the specificity was 95%.
The positive predictive value and the negative
predictive value were 79% and 97%, respectively.
35

 The NEECHAM scale proved to be a valuable
screening tool compared with the CAM-ICU in the
early detection of intensive care delirium by nurses.
 .
36

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