Delirium is typically a complex neuropsychiatric syndrome that mostly develops acutely due to disturbances in attention, cognition, and awareness. It primarily occurs in older hospitalized adults, often being unrecognized and underreported. When analyzing hospital documentations, there was no direct mention of delirium, although the potential indicators were present. However, most of these signs were confused with disorientation and mental status change. The charted referral included a minimal number of patients who were sent by the nurses to the physicians. Mainly, the latter responded by requesting diagnostic tests and prescribed medication, which included mostly benzodiazepine or antipsychotic agents (Zalon et al., 2017). The significant risks associated with delirium are extended lengths of stay, hospital readmissions, and long-term dementia or mortality. There is inadequate education in identifying those at risk and screening procedures, which significantly impediments care.
Accurate documentation of residents’ data is particularly necessary in long-term institutional care where nurses attend to many patients with severe cognitive and physical limitations. Nursing documentation attempts to facilitate information exchange on the residents under their supervision. The study examined the accuracy of these documentations and discovered that there were inconsistencies when assessed through the D-Catch instrument (Tuinman et al., 2017). It was particularly evident in the description of the care needs, outcome reports, and nursing diagnosis of the residents. However, higher accuracy scores were determined in somatic and psycho-geriatric units in residential care units. To enhance the equality of documentation, there must be an investment in resources and reasoning skills of nursing staff.
Various nursing interventions can be applied in different scenarios to solve medical problems in hospitals. For instance, in handling delirium, ICD-9 nursing intervention is applied through delirium descriptors which prove useful in providing an outline of the chart entries. The ICD-9 helps in data collection to facilitate effective decision-making. A related language relevant to the patient’s condition, which provides an overall view of the various cognitive illnesses, can be employed. Another critical strategy is collaborative teamwork in facility to ease problem solving process and cater for the inadequate staff numbers. The most prevalent observable state of residents that is an apparent indication of delirium is deprived attention and, which can be equaled to fluctuation of cognition (Zalon et al., 2017). Knowing how these terms are used and the specific situations are critical in improving accurate documentation in a way that makes the diagnosis of mental disorders or any psychological impact of a prolonged stay in such care institutions easy.
Moreover, newer screening tools should be integrated into the diagnosis of such emotional problems and treatments. HELP is a behavioral nursing intervention that is nonpharmacological and effective but less documented by nurses, and the skill circulates typically within the system orally. Additionally, other documentation-related problems can be fixed by an upgrade of LTIC and an improvement of educational background and competencies coupled with adequate staffing (Tuinman et al., 2017). It is directly related to community nursing intervention relevant for implementing healthcare initiatives to improve care. Conversely, safety nursing intervention involves applying EHR systems in enhancing the information exchange to help prevent and treat delirium (Zalon et al., 2017). The health management, policy, and resident are highly dependent on an efficient documentation system.
There is an apparent need for accurate documentation of residents’ data in long-term healthcare institutions. In the interventions required for treatment and prevention of delirium, mapping is critical. As such, the data generated therein create delirium indicators that help shape the course of medical response. Moreover, technology can be applied to make the process more effective and efficient, such as using an EHR system. Maintaining effective intervention measures helps conserve health resources and improve the quality of life for the older adults in these settings.
Tuinman, A., de Greef, M. H., Krijnen, W. P., Paans, W., & Roodbol, P. F. (2017). Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatric nursing, 38(6), 578-583. Web.
Zalon, M. L., Sandhaus, S., Kovaleski, M., & Roe-Prior, P. (2017). Hospitalized older adults with established delirium: Recognition, documentation, and reporting. Journal of gerontological nursing, 43(3), 32-40. Web.