American Journal of Critical Care. 2008;17: 502
Copyright © 2008 by the American Association of Critical-Care Nurses.
Clinical Pearls
By
Mary Jo Grap, RN, PhD, Section Editor.
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Delirium Assessment in the Intensive Care Unit
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Delirium is a condition characterized by an acutely changing or fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness, and is underdiagnosed in the intensive care unit (ICU). In this issue, Devlin et al report survey results about delirium assessment. Here are some facts about the condition:
- Although delirium is classically described as a hyperactive state (agitated or combative), more patients in the ICU with delirium are hypoactive (psychomotor slowing) or have a mixed picture.
- The primary risk factor for delirium is preexisting cognitive impairment.
- The Society of Critical Medicine practice guidelines recommend patients be routinely screened (at least once every 12 hours) for delirium using a validated screening tool.
- The ICDSC and CAM-ICU are validated delirium screening tools that are efficient and easy to use. Although few nurses involved in the studies that validated the ICDSC and CAM-ICU found the tools too time consuming to use, 90% of the nurses surveyed by Devlin et al reported that delirium is challenging to assess.
- Relying on the presence of agitation-related events or the inability to follow commands (the most commonly reported methods) to detect delirium misses patients having hallucinations, disorganized thinking, sleep disturbances, or the hypoactive subtype of delirium.
See Article, pp 555–566
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Gastric Residual Volume and Aspiration in Patients Receiving Gastric Feedings
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It is assumed that high gastric residual volumes (GRVs) increase risk for gastroesophageal reflux and associated aspiration; their measurement is recommended to reduce this risk, although this practice has been questioned.
In this issue, Metheny et al describe the relationship between GRV and aspiration. What is the practice in your unit? These researchers found the following:
- Measurement error is a significant problem in assessing GRVs. High GRVs are more likely to be obtained from large-bore tubes compared to small-bore tubes. Small-bore tubes identified up to one-fourth of the high GRVs found.
- Insufflating air through the tube prior to aspiration will improve the ability to obtain an aspirate.
- When high GRVs were present, aspiration was observed more often. But patients who aspirated frequently often did not have high GRVs, whereas patients who aspirated infrequently occasionally did.
- Aspiration risk should be evaluated in context with GRVs as well as other aspiration risk factors (level of consciousness, position of the head of the bed, sedation, vomiting, and severity of illness).
See Article, pp 512–520
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Swallowing Evaluation Prior to Extubation
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Swallowing dysfunction leading to aspiration is very common, especially after prolonged intubation, accounting for up to 15% of the cases of extubation failure.
In this issue, Colonel et al describe the evaluation of a bedside tool to evaluate swallowing prior to extubation.
- Cervical motility, a swallowing evaluation, is based on the ability to hold the head up, open the mouth, purse the lips, grit the teeth, and stick the tongue out over the lower teeth.
- Gag reflex before extubation is a good predictor of cough and ability to mobilize pulmonary secretions after extubation.
- Swallowing evaluation was predictive of successful extubation in patients intubated for more than 6 days.
- In patients with CNS disease, 3 out of 4 reintubations were predicted.
- Bedside clinical evaluations performed after extubation always underestimate the incidence of swallowing disorders.
See Article, pp 504–510
Clinical Pearls is designed to help implement evidence-based care at the bedside by summarizing some of the most clinically useful material from select articles in each issue. Readers are encouraged to photocopy this ready-to-post page and share it with colleagues. Please be advised, however, that any substantive change in patient care protocols should be carefully reviewed and approved by the policy-setting authorities at your institution.
Related articles in AJCC:
- Swallowing Disorders as a Predictor of Unsuccessful Extubation: A Clinical Evaluation
- Philippe Colonel, Marie Hélène Houzé, Hélène Vert, Joachim Mateo, Bruno Mégarbane, Dany Goldgran-Tolédano, Françoise Bizouard, Martine Hedreul-Vittet, Frédéric J. Baud, Didier Payen, Eric Vicaut, and Alain P. Yelnik
AJCC 2008 17: 504-510.
[Abstract]
[Full Text]
- Gastric Residual Volume and Aspiration in Critically Ill Patients Receiving Gastric Feedings
- Norma A. Metheny, Lynn Schallom, Dana A. Oliver, and Ray E. Clouse
AJCC 2008 17: 512-519.
[Abstract]
[Full Text]
- Assessment of Delirium in the Intensive Care Unit: Nursing Practices And Perceptions
- John W. Devlin, Jeffrey J. Fong, Elizabeth P. Howard, Yoanna Skrobik, Nina McCoy, Cyndi Yasuda, and John Marshall
AJCC 2008 17: 555-565.
[Abstract]
[Full Text]
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