DELIRIUM AND

DYSPNEA
DELIRIUM
 cognitive impairment with a
sudden onset and fluctuating
level of consciousness
DEMENTIA, DIFFERENCE
AND IMPORTANCE
gradual onset
persons LOC unimpaired and does not
fluctuate
chronic and irreversible

diagnosis provides an indication of the

likelihood of restoration of cognitive function
DELIRIUM
approximately 25-45% of episodes are
reversible
possible to have preexisting dementia

Hence, reversing the delirium in those

people will not completely restore cognitive
function.
FEATURES INCLUDES
DISTURBANCE IN
LOC, from hyperalert to somnolent
attention with ability to focus,
sustain, or shift attention
sleep-wake cycle
psychomotor behavior with changes
ranging from withdrawal to agitation
emotional state with manifestations
such as anxiety, anger, depression,
3 MAIN TYPE OF DELIRIUM
1.Hypoactive hypoalert
Calm somnolent state often manifested when
a person is actively dying or is associated
with dementia, depression, and somnolence
No treatment necessary = no sudden onset
and reversible causes ruled out
Attention to comfort is all thats required
3 MAIN TYPE OF DELIRIUM

2. Hyperactive hypoalert
(mixed)
restless somnolent state
can fluctuate between
somnolence and agitation
3 MAIN TYPE OF DELIRIUM
3. Agitated or hyperactive hyperalert
agitated, restless state w/ sudden onset
and fluctuating LOC, may or may not
include
Hallucinations
Delusions
Disorientation
Memory impairment
Distractibility
Day/night reversal
CAUSES
D- Drugs (opioids, benzodiazepines, antidepressants,
NSAIDS, ACE inhibitors, digoxin, anticholinergics, diuretics)
E- ETOH or drug use, misuse or withdrawal
L- Liver impairment
I- Infection
R- Resp. impairment (hypoxemia)
I- Intracranial pathology (brain tumour/head injury)
U- Uremia (renal impairment)
M- Metabolic abnormalities (hypercalcemia/hyponatremia)
NURSING ALERT!

Urinary retention and

constipation dont cause
delirium but may
exacerbate agitation in
cognitively impaired
ASSESSMENT
1.Hx
Speed of onset
Timing of sx (when is it better or
worse)
Changes in behavior, LOC, attention,
sleep wake cycles,
cognition/perception, emotions
Alleviating and aggravating fx
ASSESSMENT

2. Physical
examination
s/sx of possible causes
(opioid toxicity, infection,
DHN, metabolic
ASSESSMENT
3. Investigation
CBC, blood culture, electrolytes, ca
and albumin, liver and renal fn tests,
metabolic screening, u/a, CT of head,
chest xray, 02 sat
Screening tool Molloy Standardized
Mini-Mental State Examination
INTERVENTIONS
Surround the person w/ familiar objects and
people including family members and
consistent caregivers if possible
Be calm and respectful
Provide structure and routine w/ simple
explanations
Provide a quiet, well-lit room, night light,
visible clock, and calendar
Do not try to re-orient agitated persons or
IDENTIFY AND TREAT REVERSIBLE
CAUSES INCLUDING
Infection (antibiotics)
Opioid neurotoxicity (hydration and opioid
rotation)
Cerebral tumor (steroids or radiation therapy)
Metabolic abn (correct imbalances)
Medications (change/discontinue as
indicated)
PHARMACOLOGICAL
INTERVENTIONS
Haloperidol (Haldol)
0.5-2mg PO/SQ x 4-6 hrs and every hour as
needed, titrate upward to max dose of 20mg in 24
hrs
Has antipsychotic properties effective for
controlling hallucinations, restlessness, agitation
drug of choice
Methotrimeprazine (Nozinan)
2.5mg to 25mg PO/SQ x 8-12 hrs and every hour
as needed, max dose 200mg in 24 hrs.
NURSING ALERT!
In rare instances of
agitated delirium
intractable to all
measures, consider
palliative sedation.
 Lorazepam (Ativan)
Midozalam (Versed)
Quick acting benzodiazepine used to
produce sedation for cases of intractable
agitated delirium
Common starting dose is 1mg per hour via
continuous SQ/IV infusion
Titrate upward to achieve the desired level
of sedation that relieves the distress of
intractable delirium
Midazolam 2.3-5.0mg SQ loading dose
NURSING ALERT!

Any of these meds may

have a paradoxical effect
and worsen delirium. If this
occurs, refer to a palliative
care specialist.
 WHAT ARE THE
INTERVENTIONS FOR
SUPPORTING FAMILY WHEN A
PERSON
Family IS DELIRIOUS?
Counselling
sx of delirium such as moaning and
agitation are an indication of brain
malfunction and not an expression of pain or
suffering
If the person has no pain or the pain control
was good before the onset of delirium, it is
likely that the persons behavior is not due to
increased pain
 WHAT ARE THE
INTERVENTIONS FOR
SUPPORTING FAMILY WHEN A
PERSON
Family IS DELIRIOUS?
Counselling
people who recover usually have little or no
recollection of this sx after the episode of
agitated delirium resolves
The person isnt in control of what he or she
is doing or saying
The person may be comforted by having
family members present at all times. It is
advisable to take turns, if possible, to
 WHAT ARE THE
INTERVENTIONS FOR
SUPPORTING FAMILY WHEN A
PERSON
Family IS DELIRIOUS?
Counselling
attempt to provide a quiet, restful,
calm environment that minimizes
sensory stimulation to help reduce
the persons agitation.
DYSPNEA
 subjective discomfort r/t breathing
involving perception of breathlessness
and the persons reaction to it
not the same as tachypnea or hypoxia
a persons expression of dyspnea may
not necessarily correlate w/ his/her RR or
02 SAT
breathing can be compromised by
problems w/inhalation, ventilation,
perfusion, transportation, diffusion,
utilization, and/or metabolism
CAUSES
Pulmonary causes
Obstruction (tumor blockage, COPD,
emphysema, chronic bronchitis)
Restriction (pulmonary fibrosis)
Consolidation of lung tissue (pulmonary
parenchymal lesion, pneumonia, cystic
fibrosis)
Collapsed lung/ atelectasis
Pleural effusion
Pleural based tumor
Cardiovascular causes
Obstruction of pulmonary blood vessels
(pulmonary embolus, pulmonary edema or
superior vena cava syndrome)
Pericardial effusion
Anemia
Heart failure
Cardiomyopathy
Other causes
Myopathy (multiple sclerosis, muscular
dystrophy, amyotrophic lateral sclerosis)
Anorexia cachexia syndrome (persons w/
ASSESSMENT
1. Hx
Intensity how severe is the shortness of breath?
Use a 0-10 rating scale or visual analogue scale,
such as that used in the ESAS-r. how distressing is it
at rest? At worst? Best?
Quality describe how it feels (tightness in chest,
not getting enough air like suffocating or drowning)
Onset- when did the breathlessness start? Is it r/t
activity?
Duration when did dyspnea start? How long does
Aggravation what makes it worse? What
activities cause shortness of breath?
Alleviation what makes it better? How is
it managed?
Impact is there suffering when
breathing? How has the breathlessness
affected the ability to function? QOL?
ASSESSMENT
2. Physical Assessment
Increased RR, resp. pattern(abd. or
apical chest movement), cyanosis
(central and/or peripheral), restlessness,
facial expression, nasal flaring, use of
accessory muscles,
intercostal/suprasternal/supraclavicular
indrawing, tracheal tug, an inability to
ASSESSMENT
2. Physical Assessment
Palpate bony structures to
detect bone metastasis or
fractures, pain over chest wall,
equal chest wall movement
bilaterally
Percuss lung fields to detect
ASSESSMENT
2. Physical Assessment
Auscultate to assess for
alterations in air entry and/or
adventitious breath sounds
(crackles, wheezes, rubs)
ASSESSMENT
3. Investigations
O2 SAT, blood work(hemoglobin,
WBC), dx procedures(chest x-ray,
CT of chest, ECG, VQ scan, ABG,
pulmonary function test
 NON-PHARMACOLOGICAL
INTERVENTIONS
Provide reassurance (calm envi. and information)
Allow person to assume any body position which
provides relief, usually leaning forward sitting with
arms supported on a table
High Fowlers position works well for fatigued or
unconscious persons (be sure elbows are supported
Allow person to breathe as quickly as they feel they
need to through mouth or nose, regardless of
presence of supplementary O2. once, their
 NON-PHARMACOLOGICAL
INTERVENTIONS
Increase ventilation (fan blowing across the face or
over bowl of ice, open a window)
Provide relaxation therapy, massage upper back
and arms, or distraction
Provide O2 therapy if person is hypoxemic or has
low O2 SAT(titrate O2 to relieve sx as opposed to
achieving a particular O2 SAT level) be cautious of
providing high flow O2 to people with COPD as the
drive to breathe may depend on their CO@ level.
 NON-PHARMACOLOGICAL
INTERVENTIONS
Provide cool mist humidity
Maintain good oral hygiene
Teach energy conservation strategies
Offer chest physiotherapy may be useful in
persons w/ compromised bone structure (bone
metastases or osteoporosis)
Consider radiation therapy may help relieve
obstruction or inflammation 2` to tumor
NURSING ALERT!

Suctioning has a limited role

and potential benefits need
to be weighed against risks
(stimulating further
secretions)
PHARMACOLOGICAL
INTERVENTIONS
Antibiotics may relieve sx assoc.w/ chest
infection
Bronchodilators (Salbutamol sulphate
(Ventolin)2.3-5mg via nebulization x 4 hrs
PRN, max dose 6 inhalations in 24 hrs. may
alleviate obstructive bronchoconstriction 2` to
COPD or asthma
Cough suppressants (Dextromethorphan 10-
20mg PO x 4 hrs, max dose 120 mg in 24 hrs;
PHARMACOLOGICAL
INTERVENTIONS
Diuretics useful if dyspnea is
caused by pulmonary or hepatic
congestion. However, must be used
cautiously in most palliative pts as
the risk of DHN may outweigh any
potential benefit.
Expectorants (Guanifesin 200-
PHARMACOLOGICAL
INTERVENTIONS
Steroids (Dexamethasone
(Decadron) 4-10mg PO/SQ 1 to 4x
daily or Prednisone10-40 mg PO
daily) may prove useful when
dyspnea is 2` to obstruction (SVC
syndrome, radiation therapy fibrosis,
lymphangitic carcinomatosis, COPD
exacerbation
PHARMACOLOGICAL
INTERVENTIONS
Chemotherapy may help relieve
dyspnea assoc. w/ obstruction or
inflammation by shrinking tumor
bulk
Anticoagulants may reduce
dyspnea if caused by pulmonary
emboli
 SYMPTOMATIC
PHARMACOLOGICAL
INTERVENTIONS
Opioids help decrease perception of
breathlessness; fentanyl is useful if given prior to
activity-related dyspnea or for breakthrough
dyspnea; avoid nebulized opioids as research has
not proven effective
Anxiolytics rarely needed for dyspnea if
underlying cause has been treated; effective
when used in conjunction w/ an opioid to reduce
dyspnea; with severe dyspnea,
NURSING ALERT!
When a person has
become unresponsive and
appears to be actively
dying, it is appropriate to
speak to family about
discontinuing life-
prolonging measures,
including O2.
THANK YOU! End.