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ATI System Disorder Template delirium tremens_UPDATED 2022/2023
- Course
- ATI (ATI)
- Institution
- Chamberlain College Nursing
ATI System Disorder Template delirium tremens
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ACTIVE LEARNING TEMPLATE: System DisorderSTUDENT NAME Miranda DISORDER/DISEASE PROCESS DeliriumREVIEW MODULE CHAPTER Enter text. ACTIVE LEARNING TEMPLATES Alterations in Health (Diagnosis) Pathophysiology Related to Client ProblemHealth Promotion and Disease Prevention
Diagnostic Procedures Laboratory TestsExpected Findings Risk FactorsASSESSMENT
ComplicationsSAFETY CONSIDERATIONS
Interprofessional Care Therapeutic ProceduresClient Education Medications Nursing CarePATIENT-CENTERED CARE4 types of delirium: Hyperactive, hypoactive, mixed and unclassified. Considered a medical emergency.Rapid onset.Educate the client andfamily about addiction andthe goal of abstinence.Commonly associated with hospitalization of older adult clients.
physiological changes, including:neurological (Parkinson’s disease, Huntington’s disease), metabolic (hepatic or renal failure, fluid and electrolyte imbalances, nutritional deficiencies)surgery,substance use or withdrawalCardiovascular and respiratory diseases. Infections (HIV/ AIDS personal relationshipsAssess client's risk of falls or injury. Reduce environmental stimuli like noise and light.Fluctuating impairment to memory, judgment, ability to focus or calculate throughout the day. Disorientation/ confusion often worse at night and early morning.
Confusion Assessment Method (CAM)
Neelon/Champagne Confusion Scale (NEECHAM)CBC
Serum electrolytes
Blood Urea Nitrogen
Creatine Levels
Alcohol withdrawal
delirium can occur
2-3 days after
cessation of
alcohol. It is a
medical
emergency.Provide a safe and therapeutic environment.
Personal contact through touch and verbal communication.Meds can be the underlying cause of delirium. 1. Antipsychotic 2. Antianxiety
3. Short acting benzodiazepi
ne: lorazepam (Ativan)Adhere to the treatmentplan. Advise clients takingdisulfiram to avoid allalcohol. Encourage selfresponsibility
Create a low stimulus
environment, provide
emotional support.
Develop motivation and
commitment.Cognitive behavioral
therapy, acceptance and
commitment therapy, and
group therapy
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