Page 2491 - Saunders Comprehensive Review For NCLEX-RN

overmedicate.
d. Haloperidol rather than
benzodiazepines should be used to
manage acute agitation;
benzodiazepines can cause delirium.
e. If the client is at risk for harming
themselves or others, a benzodiazepine
may be prescribed.
6. Delirium
a. Global impairment of cognitive
processes with a sudden onset,
associated with disorientation,
impaired short-term memory,
hallucinations or other altered sensory
patterns, abnormal thought processes,
and inappropriate behavior.
b. Common causes include acute brain
dysfunction, sepsis, critical illness, or
overall dysfunction of vital organs.
c. Differentiating between agitation and
delirium can be difficult but is
important in targeting the cause and
implementing an appropriate
treatment approach.
d. Standardized assessment tools are
available that can be used in tandem
with RASS; one tool is the Confusion
Assessment Method for the Intensive
Care Unit (CAM-ICU).
e. Haloperidol or atypical antipsychotics
can be used for hyperactive delirium.
f. Preventive measures for delirium
include spontaneous awakening for
sedated clients, daily delirium
monitoring using a standardized tool,
mobility, and initiation of sleep
protocols where nursing care is
clustered to provide uninterrupted rest
periods.
XIII. Complex Immune Problems
A. Anaphylaxis

1. A serious and immediate hypersensitivity reaction
that releases histamine from the damaged cells
2. Anaphylaxis can be systemic or cutaneous (localized).
3. Assessment (Fig. 69-30)
4. Interventions (see Priority Nursing Actions)

2491