Patients' experiences of being delirious

AIM

The aim was to describe patients' experiences of being delirious.

BACKGROUND

Delirium is a serious psychiatric disorder that is frequently reported from hospital care settings, particularly among older patients undergoing hip surgery. It involves disturbances of consciousness and changes in cognition, a state which develops over a short period of time and tends to fluctuate during the course of the day. It is a certified fact that delirium is poorly diagnosed and recognized although the state often is described as terrifying. To be able to give professional care, it is of the utmost importance to know more about patients' experience of delirium.

METHOD

Included in the interviews were patients who had undergone hip-related surgery and during the hospital stay experienced delirium. Fifteen patients participated in the interviews. Of these, six had experienced episodes of nightly delirium (sundown syndrome) and nine experienced delirium during at least one day. The interviews were analysed by qualitative content analysis.

RESULTS

The entry of delirium was experienced as a sudden change of reality that, in some cases, could be connected to basic unfulfilled physiological needs. The delirium experiences were like dramatic scenes that gave rise to strong emotional feelings of fear, panic and anger. The experiences were also characterized by opposite pairs; they took place in the hospital but at the same time somewhere else; it was like dreaming but still being awake. The exit from the delirium was associated with disparate feelings.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to understand patients' thoughts and experiences during the delirious phase to be able to give professional care, both during the delirium phase and after the recovery.

A Multidisciplinary Approach to Total Joint Replacement

A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon's office through postdischarge rehabilitation. Project goals for the team were to develop the "ideal" pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a user-friendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients.

Cost of care for seniors hospitalized for hip fracture and related procedures

Hospitalization and treatment for hip fracture and elective hip replacement surgery are increasing as the number of elderly increases and with new surgical breakthroughs. Little research has been conducted on the interventions and other variables that impact cost of care; no research has been published that includes the impact of nursing care on hospital cost. To explain the cost of hospital care that includes nursing interventions for an older patient population hospitalized for a hip fracture and/or related procedure. An effectiveness research model composed of patient characteristics, clinical conditions, nursing unit characteristics, medical, pharmacy, and nursing interventions related to the outcome of hospital cost was tested using GEE analysis. The analysis included 195 variables systematically reduced to 71 that were then examined in a sample of 568 hospitalizations (n = 523 patients, > or = 60 years old) admitted for treatment of a hip fracture or elective hip procedure over a 4-year period. Data were obtained retrospectively from nine clinical and administrative data repositories from one tertiary care hospital. The best predictors of increased hospital cost were the nursing intervention of Tube Care, the level of RN staffing below the unit's average, total number of medical procedures, total number of different medications, and low levels of the nursing intervention of Surgical Preparation. More RN hours per patient day and some nursing interventions were associated with reduced cost. The study demonstrates the importance of conducting effectiveness research in nursing. Some nursing interventions were associated with increased cost and some with decreased cost, but when compared with medical and pharmacy interventions, fewer nursing interventions were associated with increased cost. Inadequate RN staffing raised cost whereas increased RN staffing was associated with lower costs.

Patterns of Nursing Intervention Use Across 6 Days of Acute Care Hospitalization for Three Older Patient Populations

PURPOSE

The purpose was to (a) identify frequently used nursing interventions, and (b) describe patterns of interventions used for each of the three patient groups.

METHODS

This secondary data analysis used data from an academic medical center where the Nursing Interventions Classification (NIC) was used to electronically document nursing care. Descriptive statistics describe the types, frequencies, and patterns of NIC interventions delivered to three older acute care populations.

FINDINGS

Four NIC treatments were frequently used in all patient groups. There were also NIC treatments and patterns of treatments that were unique to each group.

CONCLUSIONS AND IMPLICATIONS

Using standardized nursing language in electronic medical records (EMRs) enables data extraction and analysis. Data extracted from EMRs provides nurse administrators with a tool to guide decisions regarding nurse staffing, education, evaluation, and resource allocation.

The Effect of Music on Pain and Acute Confusion in Older Adults Undergoing Hip and Knee Surgery

The purpose of this study was to examine the effects of music listening in older adults following hip or knee surgery. Acute confusion and pain after surgery can increase length of stay and reduce function. Study results demonstrate a reduction in acute confusion and pain and improved ambulation and higher satisfaction scores in older adults who listened to music.

Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures

BACKGROUND

The research on hip fractures has been focused on surgical procedures for hip fracture repair; little is known about the contribution of nursing interventions to outcomes.

OBJECTIVES

To investigate factors, including nursing interventions, associated with the discharge destination of an older patient population hospitalized for a fractured hip or an elective hip procedure. Nursing interventions used during the hospitalized period are identified.

METHODS

A design model composed of patient characteristics; clinical conditions; nursing unit characteristics; and medical, pharmacy, and nursing interventions related to the outcome of discharge disposition was tested using generalized estimating equations analysis. A total of 116 variables were examined in a sample of 569 hospitalizations from 524 patients aged 60 years and older admitted for treatment of a hip fracture or elective hip procedure in one tertiary care agency over a 4-year period. Data were obtained retrospectively from five clinical databases.

RESULTS

Fifty-four percent of the population was discharged to a location other than to home. The predictors of discharge to home were a younger age, admission from home, and having a spouse, as well as receipt of intravenous solutions, diagnostic ultrasound, a lower number of medications, and moderate use of the nursing intervention of bathing. The identification of nursing interventions indicates that those who received routine nursing care for this condition returned home while those who required interventions for complications or prevention of complications were discharged to an institution.

DISCUSSION

Using a standardized nursing language with the hospital's information system can provide nurses and others with information that demonstrates the contribution of nursing care to outcomes, including the outcome of discharge to home.

[Accelerated versus conventional hospital stay in total hip and knee arthroplasty II: organizational and clinical differences]

INTRODUCTION

The goal of this study was to evaluate hospital stays for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA) in order to identify important logistical and clinical areas for the duration of the hospital stay.

MATERIALS AND METHODS

According to the National Register on Patients, the three departments with the shortest and the three departments with the longest postoperative hospital stay at the end of 2003 were chosen for evaluation. This took place from late 2004 to mid 2005, and all written material and 25 journals from each department were evaluated, and interviews with the heads of the departments as well as the staff were conducted. The logistical set-up and the clinical treatment/pathway were examined in an attempt to identify logistical and clinical factors acting as improvements or barriers for quick rehabilitation and subsequent discharge.

RESULTS

Departments with short hospital stay were characterised by both logistical (homogenous entities, regular staff, high continuity, using more time on and up-to-date information including expectations of a short stay, functional discharge criteria) and clinical features (multi-modal pain treatment, early mobilization and discharge when criteria were met) facilitating quick rehabilitation and discharge.

CONCLUSION

Implementation of logistical and clinical features, as shown in this study in all departments, are expected to increase rehabilitation and reduce the length of hospital stay.

[A project to provide instruction in the nursing of elderly patients with total hip replacement (T.H.R.)]

This project was aimed at improving the nursing of patients who have undergone total hip replacements. Investigation showed the following problems with existing nursing instruction in this area: lack of standard instruction, outdated educational materials, a 33.75% rate of completion of instruction lack of familiarity with instruction materials, and an average satisfaction score of 2.56 among nurses who have undergone instruction; The reading for patient's satisfaction with the guidance of nurses was 2.04. After site investigation, status analysis and reference check, we proposed the following program. (1) Establish standards and monitor tools for instruction for nursing total hip replacement patients, including "Caring standard", "Guidance for nursing instruction", "Nursing instruction sheet", "Notes at nursing instruction", "Satisfaction scoring system for nursing instruction"; (2) Carry out a training course to enhance nursing staff's knowledge about caring for patients with total hip replacement. After program had been implemented, a completion rate of 88.56% was achieved, and the satisfaction scores among nursing staff and patients were 4.3 and 4.36 respectively. This result shows that when we undertake reform at various different levels--including systemic structure, processing and monitoring--this can radically improve the quality of nursing instruction.

Arthroscopic hip surgery

Many pathological entities that previously could be accessed only through large, open incisions now can be treated arthroscopically. Furthermore, arthroscopy has allowed certain conditions to be diagnosed that previously were unrecognized. Arthroscopic hip surgery has become an accepted surgical procedure with well-defined indications and expected outcomes, primarily because of recent advances in surgical instrumentation and techniques. Hip arthroscopy is performed as a same-day procedure using a fracture table to apply distraction to the hip joint. Coordination among surgeons and perioperative nursing staff members is essential for achieving consistent results and minimizing complications during this technically demanding procedure.

Revision total hip and total knee arthroplasty

For thousands of patients with advanced degenerative joint disease, total joint arthroplasty provides improved function, decreased pain, and the opportunity to resume a more active lifestyle (Drake, Ace, & Maale, 2002). Although hip and knee replacements are both successful interventions for degenerative joint conditions, complications may arise that require revision of the original surgery. In 1999, approximately 25,000 revisions of knee replacements (ICD Code 81.22) and 30,000 revisions of hip replacements (ICD Code 81.53) were performed in the United States (American Academy of Orthopaedic Surgeons [AAOS], 2002). Approximately 10,000 revision total hip arthroplasty procedures were performed on Medicare patients in 2000. The total cost of revision surgery, including the 10,000 total knee revision procedures performed on this same patient population during that year, exceeds USD 3 billion (Bourne, Maloney, & Wright, 2004). Descriptions of the risk factors and indications for revision total hip and total knee arthroplasty are included in this article. Nursing interventions and patient education specific to these patient populations are outlined, and a discussion of complications following revision total joint arthroplasty is included.

Effects of multimedia with printed nursing guide in education on self-efficacy and functional activity and hospitalization in patients with hip replacement

This study aimed to examine the effects of multimedia with printed nursing guides in patient education on the improvement of self-efficacy, functional activity and length of hospitalization in patients with hip replacement. A quasi-experimental design was used. Control group received a routine care, whereas experimental group was given the multimedia with printed nursing guides. In the multimedia, CD is a collection of nursing instructions in the format of multimedia such as video and audio recorded into a CD. The result showed there are statistically different between experimental and control groups on self-efficacy (t = -7.93, P < 0.001), functional activities (t = 4.33, P < 0.001), and length of hospitalization (t = 2.54, P < 0.05). The findings indicated experimental group achieved higher self-efficacy with the help of multimedia with printed nursing guides. Control group needed more assistance in performing functional activities. Length of hospitalization was significantly shorter in experimental group than in control group. To better adapt to continual human resource reduction and to improve nursing service quality, wider applications of multimedia with printed nursing guides in patient education may be worthwhile.

The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery

This study was undertaken to determine the effect of music on elders undergoing elective hip and knee surgery who experience acute confusion and delirium postoperatively. Postoperative confusion and delirium in elders often cause complications that negatively effect recovery. Music listening was introduced as an intervention to an experimental group. Nurses documented episodes of acute confusion and delirium experienced by elders postsurgically. Scores from a readiness-to-ambulate profile to determine if patients were cognitively ready for postoperative therapy were evaluated. There was a significant decrease in the number of episodes of postoperative confusion among those in the experimental group compared with those in the non-listening control group. In addition, the experimental group had significantly higher scores on the readiness-to-ambulate profile than the control group. These findings indicate that music listening is an effective nursing intervention that can be used to decrease acute postoperative confusion and delirium in elders undergoing elective hip and knee surgery.