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Introduction

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Anxiety, pain, and delirium are common in intensive care patients and may be due any one of or combinations of the following factors: disorientation, medications, or the underlying disease. While anxiety can often be relieved by compassionate staff, agitation and delirium can result in patient actions that put them at risk for falls, dislodgement of medical devices, or disruption of wound dressings and incisions. Appropriate management of these problems requires early identification, differentiation among the potential causes, and appropriate treatment.

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Definitions and Terms

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  • ▪  Anxiety: An unpleasant emotional state consisting of a set of mental and physiologic responses to anticipated real or imagined danger—the mental responses include apprehension, tension while the physiologic responses include increased heart rate, respiratory rate, sweating, weakness, and fatigue.
  • ▪  Delirium: An acute, short-term disturbance in consciousness characterized by disorganized thoughts, inability to focus attention, disorientation, sensory misperceptions and may result in paranoid ideation, sleep disturbances, excessive or inappropriate motor activity, and memory impairment.
  • ▪  Agitation: Excessive, purposeless cognition and movement manifested as restlessness.
  • ▪  Agitation scale: One of several scales designed to provide caregivers with a uniform, objective measure of a patient’s mental status—common scales in use include:
    • —Ramsey scale
    • Ranges from no response at one extreme to agitated and restless at the other (six-point scale: 1–6)
    • —Riker sedation agitation scale
    • Ranges from unarousable to dangerous agitation (seven-point scale: 1–7)
    • —Motor activity assessment scale
    • Ranges from unresponsive to dangerously agitated (seven-point scale: 0–6)
    • —Richmond agitation sedation scale
    • Ranges from sedated to combative at the other and includes verbal and physical stimuli (ten-point scale: −5 to 4)

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Techniques

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  • ▪  Agitation scales are typically applied at the bedside by medical providers.
  • ▪  Treatment for agitation, disorientation, and delirium typically requires treatment of the underlying problem where identifiable.
  • ▪  Anxiety and disorientation can be treated with reassurance, reorientation, recreation of a familiar environment with props such as pictures, assistance from family members, friends, and others.
  • ▪  Anxiolytics such as benzodiazepines can be used when nonpharmacologic alternatives are insufficient or inadequate.
  • ▪  Benzodiazepines are often useful in the management of drug or alcohol withdrawal.
  • ▪  Antipsychotic agents such as haloperidol can be used in patients with delirium refractory to other interventions.
  • ▪  Pain and sleep medications should be used when pain or sleeplessness are possible contributors.

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Clinical Pearls and Pitfalls

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  • ▪  Critically ill patients may be “disoriented” for a variety of reasons including:
    • —Neurological process such as head injury, encephalitis, and so on.
    • —Drug side effect.
    • —Dementia, which may be subclinical in a patient’s home environment but become manifest during a hospitalization—this typically occurs in the elderly.
    • —Drug or alcohol intoxication.
    • —Drug or alcohol withdrawal.
    • ▪  The differential diagnosis for delirium includes many of same processes causing disorientation as well as:
    • —Focal seizures
    • —Primary psychiatric processes such as depression, mania
    • —Sleep deprivation
    • —Systemic and intracranial infection/sepsis
    • —Fever
    • —Electrolyte and metabolic disturbances
    • ▪  Delirium ...

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