Zimberg M, Berenson S
Memorial Sloan-Kettering Cancer Center, New York.
Oncol Nurs Forum. 1990 Jul-Aug;17(4):529-38.
Delirium has been found to occur in 25% to 40% of patients with cancer at some time during their illness and has been reported to be as high as 85% in patients with advanced disease. The cognitive and behavioral changes associated with delirium cause emotional distress to the patient and family. More seriously, delirium can lead to dementia or death if untreated. The initial stages of delirium are frequently confused with anxiety. The nurse plays a crucial role in the identification of delirium. Effective intervention requires early assessment of the etiology of delirium and its associated cognitive impairments. Some of the physiological sources are: vascular, metabolic, infectious, respiratory, and cerebral disorders. Analgesics, chemotherapeutic agents, and other medications can also cause delirium. Additionally, recent clinical reports identify monoclonal antibodies, interleukin 2, and ifosfamide as contributing to delirium. In order to adequately differentiate anxiety from delirium, the nurse assesses cognitive functioning which includes attention-concentration, recent memory, orientation to immediate environment, and sensory-perceptual functions. Nursing interventions are directed toward organizing the patient's environment and providing reassurance to the patient and family. Collaboration with the medical team is essential in treatment of the underlying organic causes. Patient outcomes serve as the evaluation criteria for the effectiveness of nursing interventions. This presentation offers a standard of care which describes the nursing diagnoses associated with delirium, specific assessment criteria, interventions, and expected patient outcomes. Delirium represents a quality of life issue. This standard of practice provides the means for the nurse to have an impact on the patient's and family's quality of life.
据发现，25%至40%的癌症患者在患病期间的某个时候会出现谵妄，据报道，晚期疾病患者的谵妄发生率高达85%。与谵妄相关的认知和行为变化给患者及其家人带来了情绪困扰。更严重的是，如果不进行治疗，谵妄会导致痴呆或死亡。谵妄的初始阶段常常与焦虑相混淆。护士在识别谵妄方面起着至关重要的作用。有效的干预需要早期评估谵妄的病因及其相关的认知障碍。一些生理原因包括：血管、代谢、感染、呼吸和脑部疾病。镇痛药、化疗药物和其他药物也可能导致谵妄。此外，最近的临床报告指出单克隆抗体、白细胞介素2和异环磷酰胺也与谵妄有关。为了充分区分焦虑和谵妄，护士会评估认知功能，包括注意力集中、近期记忆、对即时环境的定向以及感觉-感知功能。护理干预旨在整理患者的环境，并向患者及其家人提供安慰。与医疗团队合作对于治疗潜在的器质性病因至关重要。患者的预后是评估护理干预效果的标准。本报告提供了一种护理标准，描述了与谵妄相关的护理诊断、具体评估标准、干预措施以及预期的患者预后。谵妄是一个生活质量问题。这种实践标准为护士提供了影响患者及其家人生活质量的方法。
