The nurse's elderly client keeps pulling at the IV, attempting to crawl of out the bed and reporting seeing her "mother" visiting her in the hospital. The nurse suspects that the client might be experiencing delirium
The nurse knows which of the below to be a cause for delirium? a. opioid medications e. vitamin deficiencies
b. urinary tract infection f. substance withdrawal
c. pneumonia g. sensory deprivation
d. dehydration h. fecal impaction
A, B, C, D, E, F, G, H
There are many causes for delirium in the medical surgical client. Medication effects (particularly those with anticholinergic properties and opioids) are responsible for many episodes of delirium. Infections, from simple urinary tract infections to pneumonia and brain infections can result in delirium, especially in the very young and the older adult. Metabolic disturbances that place extra demands on the brain such as hepatic and uremic encephalopathy, fluid and electrolyte imbalances, acid-base balance disturbances, hypoxia, hypoglycemia, and hyperthermia must be assessed for in the delirium workup. More serious neurological disorders such as brain abscesses and tumors, cerebral hemorrhage, vascular abnormalities, post-concussive syndrome, postictal states (condition after a seizure), and trauma to the head can result in varying levels of altered mental status, as well. Other common causes for delirium include vitamin deficiencies, particularly thiamine and vitamin B12, substance withdrawal and even changes in the environment, environmental noise and distraction, fecal impaction, sensory deprivation, sleep deprivation, and urinary retention.
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