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Case Study

Postoperative Delirium

Patient Profile

M.C. is a 74 year old male who has been in the intensive care unit (ICU) for 3 days after unexpected major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented.

Subjective Data

· States he needs to “get out of here”

· Angry at family members for not “taking me home”

· Family members are very upset about M.C.’s confusion

Objective Data

· Blood pressure 110/70, pulse 98, respirations 20, temperature 97.3 F

· Oxygen saturation 97% on nasal cannula oxygen at 2L

· Abdominal incision healing, no redness or drainage

· Difficulty speaking with decreased short-term memory and recall

· Trying to climb out of bed

· Oriented to person only

· Difficulty focusing attention, and disorganized thinking

Answer the following questions thoroughly and cite resources appropriately in APA format.

What type of cognitive impairment does M.C. likely have?

How can this diagnosis be confirmed?

Are there any other issues that you need to consider as possible causes for his mental state?

What is the nurse’s priority regarding M.C.’s mental status?

What is the next priority for the nurse caring for M.C.?

What diagnostic tests may be ordered and what would each contribute?

How will you support M.C.’s family at this time?

Complete the attached CAM worksheet for this patient and discuss the results here

1

Confusion Assessment Method (CAM)

(Adapted from Inouye et al., 1990)

Patient’s Name: Date:

Instructions: Assess the following factors.

Acute Onset
1. Is there evidence of an acute change in mental status from the patient’s baseline?

YES NO UNCERTAIN NOT APPLICABLE

Inattention
(The questions listed under this topic are repeated for each topic where applicable.)

2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty
keeping track of what was being said)?

Not present at any time during interview

Present at some time during interview, but in mild form

Present at some time during interview, in marked form

Uncertain

2B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come and go or
increase and decrease in severity)?

YES NO UNCERTAIN NOT APPLICABLE

2C. (If present or abnormal) Please describe this behavior.

Disorganized Thinking
3. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear

or illogical flow of ideas, or unpredictable, switching from subject to subject?

YES NO UNCERTAIN NOT APPLICABLE

Altered Level of Consciousness
4. Overall, how would you rate this patient’s level of consciousness?

Alert (normal)

Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily)

Lethargic (drowsy, easily aroused)

Stupor (difficult to arouse)

Coma (unarousable)

Uncertain

2

Disorientation
5. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere

other than the hospital, using the wrong bed, or misjudging the time of day?

YES NO UNCERTAIN NOT APPLICABLE

Memory Impairment
6. Did the patient demonstrate any memory problems during the interview, such as inability to remember

events in the hospital or difficulty remembering instructions?

YES NO UNCERTAIN NOT APPLICABLE

Perceptual Disturbances
7. Did the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or

misinterpretations (for example, thinking something was moving when it was not)?

YES NO UNCERTAIN NOT APPLICABLE

Psychomotor Agitation
8A. At any time during the interview, did the patient have an unusually increased level of motor activity, such as

restlessness, picking at bedclothes, tapping fingers, or making frequent, sudden changes in position?

YES NO UNCERTAIN NOT APPLICABLE

Psychomotor Retardation
8B. At any time during the interview, did the patient have an unusually decreased level of motor activity, such as

sluggishness, staring into space, staying in one position for a long time, or moving very slowly?

YES NO UNCERTAIN NOT APPLICABLE

Altered Sleep-Wake Cycle
9. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness

with insomnia at night?

YES NO UNCERTAIN NOT APPLICABLE

Scoring:
For a diagnosis of delirium by CAM, the patient must display:

1. Presence of acute onset and fluctuating discourse

AND

2. Inattention

AND EITHER

3. Disorganized thinking

OR

4. Altered level of consciousness

Source:
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion
assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

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Confusion Assessment Method (CAM) Diagnostic Algorithm

Feature 1: Acute Onset and Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by positive
responses to the following questions: Is there evidence of an acute change in mental status
from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day; that is, did it
tend to come and go, or increase and decrease in severity?

Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have
difficulty focusing attention; for example, being easily distractible, or having difficulty keeping
track of what was being said?

Feature 3: Disorganized Thinking
This feature is shown by a positive response to the following question: Was the patient’s
thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or
illogical flow of ideas, or unpredictable switching from subject to subject?

Feature 4: Altered Level of Consciousness
This feature is shown by any answer other than “alert” to the following question: Overall, how
would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyperalert],
lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

Source:
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion
assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

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