My most recent work week has challenged me far more than I could have expected. My shift began much like any other: I organized my patient assignments, assessed my patients, and administered medications amongst other nursing duties. But around noon, one of my patients began acting out of the ordinary. They started making comments about things that weren’t there and people I couldn’t see. This behavior has been discussed in multiple classes in the nursing school, but this was the first time that I had a witnessed it: delirium.
Delirium is a form of short-term psychosis that happens to hospitalized patients due to a number of factors, such as medication toxicity, infection, pain, lack of sleep, malnourishment, or dehydration. It is truly a misunderstood phenomenon. The psychosis that delirious patients exhibit mimics that of a dream, but they cannot distinguish the dream-state from reality.
As a nurse, it is my responsibility to assess my patient’s cognitive status at the beginning of each shift. I do this by asking the patient four questions: 1) Their full name and date of birth, 2) Where they are (the answer is usually “in the hospital,” or “Ann Arbor,” 3) what they are there for, and 4) what the current month and year is. If they answer all of these questions correctly, we call this patient “alert and oriented x 4.”
At the start of this shift, this patient was alert and oriented x 4. But as the shift progressed, they became less oriented. When patients make delusional statements that are incongruent to the situation, it is important to re-orient the patient by helping them identify where they are and what is happening (never feed into delusions!). The delirium that this patient was experiencing was severe enough to the point where the physician authorized a patient-attendant (also known as a patient sitter). The primary role of the patient attendant is to assure the safety of the patient, and in many cases remind patients to not pull their IVs out.
As the patient’s delirium worsened, they became more aggressive with the clinical staff and patient attendants. One patient attendant stated that the patient tried to hit her, which of course is a terrible sign. As a result, the patient attendant called her manager to have her assignment switched. Because they were so aggressive with the patient attendant, I spent an hour acting as a patient attendant. During that time, the patient became increasingly disoriented, accusing me of trespassing in their apartment, calling for family members that were not present in the room, stating that they wanted to hang their IV fluids in the refrigerator, and even calling the police on me for “trespassing”!
By the end of the evening, the patient tore their IVs out of their arm, and went into the hallway in a fit and attempting to leave. At this point, a nurse called for a “yellow card,” which is the hospitals way of calling for security officers to help manage a patient. Yellow card situations typically involve aggressive, combative, or highly disoriented patients. Additionally, the residents were called immediately to assess the patient and determined that they were unfit to make their own medical decisions and therefore could not leave the hospital against medical advice.
I had mixed feelings about this situation. Working with aggressive and delirious patients is definitely a challenge that you don’t see every day. First, I wondered if the situation could have deescalated sooner by calling a yellow card earlier in the shift, like when the patient attempted to hit the patient attendant. I personally wish I called for security sooner, as it may have helped the patient calm down. Secondly, this patient was highly aggressive with me and other clinical staff by the end of the shift. However, I love giving people the benefit of the doubt, and I truly believed that this patient was a kind person. This was confirmed by those that worked with this patient during the previous week. It is sad to see how this temporary psychotic state changes a person so immensely. It forced me to be more conscientious of my care, as I want to treat this patient with the same dignity and respect as any other patients. Because delirium is so misunderstood, I am guessing the unfortunate truth is that some patients in these temporary psychotic episodes do not receive the care and respect that they deserve.
This patient was on my assignment the following day, and to my surprise they were fully oriented and even somewhat pleasant to work with! It goes to show how misunderstood this condition is, and how greatly it can change people in the blink of an eye.
Treat everyone as equals; treat everyone with respect.