Dissertations / Theses on the topic 'Acute confusion'

This simple quantitative descriptive case controlled research compared cases (subjects at risk for acute confusion) with controls (subjects without the attribute); comparison was made on the exposure to potential contributing factors suspected of causing acute confusion, for example, heavy smoking, or the number of alcoholic drinks consumed per day. Case-control studies were also retrospective, because they focused on conditions in the past that might have caused subjects to become cases, rather than controls. The basic purpose of this research design was essentially the same as that of experimental research: to determine the relationships among variables. This report demonstrates that, with relatively good adherence by the nursing team, proactive screening using a structured risk assessment protocol can be successfully implemented for medical patients. This assessment was associated with a statistically significant 50 per cent reduction in the incidence of acute confusion in the intervention group, compared with usual care retrospectively. Reduction in acute confusion was not associated with shortened length of stay, but length of stay was often predetermined by protocol or critical pathway. Correlation analysis demonstrated that risk screening appeared most effective in preventing or reducing acute confusion in patients without preadmission dementia or ADL impairment. In patients with significant preadmission impairment, the stress of hospitalisation may be sufficient to precipitate an episode, despite otherwise optimal management. Less-impaired patients may require additional insults to precipitate acute confusion, some of which are avertable by risk screening and subsequent early intervention. Determined risk indicators were consistent throughout the four year timeframe set for this research project. This demonstrated that although there were multiple patient types presenting to this clinical area, they were consistently the same over a longitudinal timeframe. It meant they were reproducible, which gave this research additional strength. Also, based on the descriptive statistics, this research has shown that in this clinical area where intervention was introduced the combination did have a positive impact on annual numbers of acute confusion. In summary, these findings suggest that without risk screening and the direction for appropriate management the likelihood of an episode can more than double. In the three subgroups expected to pose the greatest challenges for the risk assessment (i.e. those 70 years or older, those with suspected drug dependency, and those with symptomatic infection), risk assessment retained excellent sensitivity, (a) (d) specificity, and relevant correlation with reduction of episodes. This research has demonstrated throughout that high risk screening and associated intervention based on the risk indicator can decrease the annual number of actual episodes of acute confusion. Interventions to prevent or reduce an episode of acute confusion, as outlined by Wakefield (2002) and this research, definitely increases as a result of high risk screening. Beyond doubt, from both the literature reviewed and the findings of this research, is that risk screening does need to be adapted to the individual clinical setting and cannot be generic.

The primary objective of this project is the development and implementation of an educational program for the staff nurses for the effective management of Acute Confusion (AC), Delirium among hospitalized patients at Kaiser Hospital in Fontana.

Akut förvirring är en kognitiv förändring som uppkommer plötsligt. Drabbade patienter upplevs exempelvis agiterade, rastlösa och apatiska. Patienter beskriver upplevelsen av akut förvirring som en abstrakt verklighet, vilket komplicerar vårdprocessen. Syftet var att beskriva sjuksköterskors erfarenhet kring vårdandet av akut förvirrade patienter. Metoden som användes var en litteraturstudie med systematisk ansats där databearbetningen inspirerades av kvalitativ innehållsanalys. Litteraturstudien visar att sjuksköterskor som möter akut förvirrade patienter på vårdavdelningar kan uppleva ökad tidspress och stress. Den akut förvirrade påverkar även övriga medarbetare och patienter, kräver mer resurser i form av övervakning och sjuksköterskor med rätt kompetens. Sjuksköterskor fokuserar på att bevara säkerheten för de akut förvirrade patienterna, detta uppmärksammas mer än människan bakom den akuta förvirringen. Sjuksköterskors förhållningssätt till de akut förvirrade blir att försöka få kontroll över patienterna genom olika strategier. Okunskap om akut förvirring visas genom att sjuksköterskor inte använder sig av vetenskapligt baserad kunskap. Prioritering blir nödvändigt för att effektivisera arbetet och för att sjuksköterskor ska kunna vara tillgängliga åt alla patienter - effektivisering av tid faller på bekostnad av akut förvirrade patienter. God kommunikation och medvetenhet om den åldersdiskriminering som förekommer är av vikt för att patienters upplevelser ska bli optimala och leda till minskat lidande vid akut förvirring.
Acute confusion is a cognitive impairment that occurs suddenly. Affected patients are for example perceived as agitated, restless and apathetic. Patients describe the experience of acute confusion as an abstract reality, this complicates the care process. The aim of this study was to describe nurses’ experience in the care of acutely confused patients. The method was a literature study with a systematic approach where the data processing was inspired by qualitative content analysis. The literature study shows that nurses who meet acute confused patients in wards may experience a lack of time and increased stress. The patient with acute confusion also affects other health careers and patients, requiring more resources in terms of monitoring and nurses with the right skill sets. Nurses are more focused on preserving the safety of the acutely confused patients than the person behind the acute confusion. Nurses’ attitudes towards the acutely confused patients are based on gaining control of the patients through various strategies. Unawareness of acute confusion is displayed by nurses’ inconsistency of the use of evidence-based knowledge. Prioritizing work is necessary to make the work more effective, it also helps the nurse to be at hand for all patients, although, managing and using time more effectively falls at the expense of the acutely confused patients. Good communication and awareness of the ageism that occurs is of importance so that the patients’ experiences become optimal and for reduction of suffering when in or after an acute confusion state.

Bakgrund: Intensivvårdspatienter utsätts för en påfrestande situation, vilket kan bidra till utvecklandet av iva-delirium. Iva-delirium är en form av hjärndysfunktion som leder till ökad sjuklighet, ökad mortalitet och ökade vårdkostnader i form av förlängd vårdtid. Studier visar att trots att iva-delirium är vanligt förekommande inom intensivvården så missas tillståndet ofta. Bedömningsinstrument för att identifiera iva-delirium finns men används vanligen i liten utsträckning inom svensk intensivvård. Detta kan leda till att intensivvårdssjuksköterskor, utifrån personlig erfarenhet, utvecklar olika strategier för att vårda patienter med iva-delirium. Syfte: Att beskriva intensivvårdssjuksköterskors personliga erfarenheter av att bedöma patienter som riskerar att drabbas av iva-delirium samt hur syndromet identifieras och förebyggs. Metod: En kvalitativ studie innehållande sex intervjuer genomfördes och analyserades utifrån en deskriptiv innehållsanalys. Resultat: Resultatet visade att intensivvårdssjuksköterskorna med hjälp av personliga erfarenheter skapade en framförhållning genom att förutse riskfaktorer och att identifiera kliniska tecken. Vidare visade intensivvårdssjuksköterskorna en förmåga att förebygga och resonera kring utförda åtgärder. En förståelse för vården av patienter med iva-delirium skapades genom etiska reflektioner. Slutsats: Intensivvårdssjuksköterskornas erfarenheter utgjordes av tre domäner; att se, att göra och att känna. Dessa olika erfarenheter interagerade med varandra, skedde simultant och skapade ett expertkunnande hos intensivvårdssjuksköterskorna. Trots denna förmåga framkom det att intensivvårdssjuksköterskornas kunskaper om iva-delirium och deras strategier varierade beroende på personlig erfarenhet. Klinisk betydelse: Genom att belysa intensivvårdssjuksköterskornas erfarenheter kan en ökad medvetenhet kring iva-delirium skapas och därmed förhoppningsvis medföra minskad prevalens.
Background: Critical care patients are exposed to a stressful situation, which could contribute to the development of icu-delirium. Icu-delirium is a form of brain dysfunction leading to higher morbidity, higher mortality and higher cost of care due to extended hospital stays. Even though studies show that icu-delirium is common within critical care the syndrome is often unrecognized. Delirium screening tools exist but are rarely used within Swedish critical care. The low implementation of screening tools could lead to that critical care nurses, based on personal experience, develop individual strategies for care of patients with icu-delirium. Aim: To describe experiences of assessing patients with risk for developing icu-delirium and how the syndrome is identified and prevented by critical care nurses. Methods: A qualitative study with six interviews was conducted and analyzed based on a descriptive qualitative content analysis. Results: The results showed that critical care nurses, based on earlier experiences, created an anticipation by discerning risk factors and identifying clinical signs. The critical care nurses showed an ability to perform preventive measurements while reasoning about already performed measurements. Through ethical reflections an understanding for the care of patients with icu-delirium was created. Conclusions: The experiences by critical care nurses was based on three domains; to see, to do and to feel. These domains occurred simultaneously and created the expertise of the critical care nurse. Despite this ability the knowledge of critical care nurses and their clinical assessment methods varied depending on earlier experiences. Relevance to clinical practice: By illuminating the experiences of critical care nurses hopefully a higher awareness regarding icu-delirium is created which will hopefully result in a lower prevalence.

The aim: was to describe and compare a group of experts and critical care nurses' agreement in detecting delirium in intubated, ventilator treated patients with sedation / analgesia, before and after an in house training intervention with the instrument Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Method: A quasi-experimental study, one group pretest - posttest design. A convenience sample of 17 critical care nurses in a general intensive care unit included. To detect delirium the instrument CAM-ICU was used, 21 paired tests before and 22 after an educational intervention. Main Results: The results showed that after an in house training intervention sensitivity and kappa coefficient improved of the characteristic 1 "acute onset and fluctuating course," an improvement that was significant. In other features, and overall values were signs of numerical improvement and deterioration in sensitivity, specificity and kappa coefficient but no significant change. Conclusion: Implementing a new instrument for detecting delirium in clinical practice requires education and follow-up. A small sample of critical care nurses with varying ability to use the new instrument and the fact that patients' status may change rapidly making it difficult to draw any conclusions from this study. It is clear, however, that education and follow-up is needed when new care routines are introduced, and that further studies are needed to clarify whether the CAM-ICU is a valit and reliable instrument to use in clinical practice.
Syftet var att beskriva och jämföra en expertgrupp och intensivvårdssjuksköterskors överensstämmelse i att detektera delirium hos intuberade, respiratorbehandlade patienter med sedering/analgesi, före och efter en utbildningsintervention med instrumentet Confusion assessment method for the intensive care unit (CAM-ICU). Metod: En kvasiexperimentell studie, en grupps pretest – posttest design. Ett bekvämlighetsurval på en allmän intensivvårdsavdelning där inkluderades 17 intensivvårdssjuksköterskor. För att detektera delirium användes instrumentet CAM-ICU, 21 parmätningarna före och 22 efter en utbildningsintervention. Huvudresultat: Resultatet visade att efter utbildningsinterventionen förbättrades sensitiviteten och kappa koefficienten i kännetecken 1 ”akut insättande eller fluktuerande förlopp”, en förbättring som var signifikant. I övriga kännetecken och totalvärden fanns tecken på numerär förbättring och försämring i sensitivitet, specificitet och kappakoefficient men ingen signifikant förändring. Slutsats: Att implementera ett nytt instrument för att detektera delirium i klinisk verksamhet kräver utbildning och uppföljning. Ett litet sample av intensivvårdssjuksköterskor med varierad förmåga att använda det nya instrumentet samt det faktum att patienters status hastigt kan förändras gör det svårt att dra några slutsatser av denna studie. Klart är dock att utbildning och uppföljning behövs när nya vårdrutiner införs, och att ytterligare studier behövs för att klargöra om CAM-ICU är ett valit och reliabelt instrument att använda i klinisk verksamhet.

Syftet med litteraturstudien var att beskriva vilka faktorer som i omvårdnadsforskningen beskrivs som bidragande faktorer till akut delirium. Syftet var vidare att beskriva vilka omvårdnadsåtgärder som omvårdnadsforskningen tar upp som kan minska risken för uppkomst av akut delirium. Resultatet baserades på vetenskapliga artiklar som söktes i följande databaser: Elin@dalarna, BlackwellSynergy, PubMed och EBSCO host. Följande sökord användes: delirium, acute, elderly, nursing, patients, caring, management, confusional state, needs. Artiklarna granskades enligt en granskningsmall med avseende på vetenskaplig kvalité. Betydande riskfaktorer för akut delirium var ålder, flera samtidiga sjukdomar, antalet mediciner och typ av medicin. Förutom att genomgå operation var också många åtgärder, framför allt invasiva åtgärder, tidigt under sjukhusvistelsen riskfaktorer för akut delirium. Även flera rumsbyten var en riskfaktor. Viktiga åtgärder för att förebygga akut delirium var psykiatrisk konsultation, tekniker för att underlätta orientering, emotionellt stöd, patientundervisning och anhörigundervisning, patientorientering, fysisk kontakt med patient samt att upprätta kontakt med kurator.

Delirium is a severe neuropsychiatric syndrome, characterised by the acute onset of inattention, altered level of arousal, and other mental status abnormalities. Delirium is extremely common in acute stroke, affecting at least 1 in 5 such patients admitted to hospital. It is a serious complication of stroke, being associated with higher mortality, longer length of hospital stay and higher dependency at discharge. The pathophysiology of delirium is not completely understood, and there are no specific treatments. This thesis investigated the role of cortisol in the development of delirium after stroke and also investigated the role of delirium and of cortisol in the development of cognitive impairment in the 12 months after stroke. The thesis specifically investigated whether levels of cortisol in saliva are elevated in delirium and also whether there is a loss of the normal diurnal rhythm in delirium, evidenced by elevated afternoon salivary cortisol levels and reduced morning level to afternoon level ratio. The thesis also investigated whether cortisol levels are persistently elevated in the year after stroke in those who developed delirium and whether cortisol levels are associated with cognitive decline. Finally it investigated whether acute and/or chronic changes seen on Computed Tomography (CT) brain scans taken around the time of stroke onset are associated with the development of delirium after stroke A longitudinal cohort study was conducted in 95 participants aged 60 years or over, who were admitted to hospital with a clinically confirmed stroke. Participants gave informed consent, or proxy consent was obtained if they lacked capacity to consent. At baseline participants underwent brief cognitive testing and were then assessed for the presence of delirium, using DSM IV criteria, at regular intervals during the first two weeks after stroke. At each assessment a saliva sample was collected in the morning and in the afternoon, to measure cortisol. Participants were then visited at 1 month, 4 months and 12 months after stroke onset, at which point they were assessed for the presence of delirium, further saliva samples were taken and a cognitive test battery was completed. 26 (27%) participants developed delirium during the course of the study period. The study found elevated salivary cortisol levels in those with delirium at up to 4 months after stroke, but at 12 months there was no difference between the delirium and no delirium group. A loss of the diurnal rhythm was seen in those who developed delirium at 5 days after stroke, but the diurnal variation had returned to a normal pattern at follow-up. However, in a multivariate analysis, controlling for age, sex, stroke severity (NIHSS), current illness burden (APACHE II), chronic illness burden (CCI) and prior cognitive impairment (IQCODE), neither median salivary cortisol levels in the first two weeks after stroke, nor the ratio of morning to afternoon cortisol levels were independent predictors of delirium diagnosis, although median 9am cortisol approached significance (OR=0.95, 95% confidence interval (CI) 0.89-1.01, p=0.08). In a random effects logistic regression analysis, the probability of developing delirium decreased over time from stroke onset and increased per unit increase in salivary cortisol (nmol/L), however this effect was not statistically significant (OR 1.02, CI 0.84-1.19 P=0.70 for morning cortisol and OR 1.05, CI 0.82-1.25 p=0.46 for afternoon cortisol). Global cognition, measured by the MoCA, was significantly poorer in the delirium group at each time point throughout the 12 months after stroke. However, there was a trend towards improvement in MoCA scores in the whole cohort throughout the 12 month follow-up, with the exception of those who developed the most severe delirium. The presence of delirium at any point during the 12 month follow-up did not affect the rate of change of the MoCA scores over the 12 months after stroke. The presence of brain atrophy identified on admission CT brain scans was independently associated with delirium (OR 3.7, CI 1.15-11.88, p=0.02), however the presence of a visible acute or chronic stroke lesion and the presence of white matter lesions were not. Finally, those who developed delirium had a worse functional outcome, longer length of hospital stay and were more likely to require institutional care or a package of care at home, compared with those who did not develop delirium. This thesis has contributed to our understanding of the mechanisms and phenomenology of delirium after stroke, and has also highlighted areas for further research which will be required to unpick the complex pathophysiology of delirium.

Delirium is common among old patients admitted to hospital, but is often a neglected problem in patient care. The principal aim of this thesis was to evaluate aspects of delirium in relation to incidence, risk factors, behavioural changes, cognitive function and health-related quality of life (HRQOL). A further aim was to describe patients’ experiences of being delirious. The study was prospective, descriptive and comparative, with repeated measures (six-month follow up). The sample consisted of 225 consecutive patients, aged 65 years or older, who were to be operated on due to hip fracture or hip replacement. Exclusion criteria were serious cognitive disorder or delirium on admission. Data were collected via frequent daily observations, cognitive functioning tests (MMSE), HRQOL questionnaires (SF-36) and interviews. Delirium was assessed according to the DSM-IV criteria. A total of 45/225 became delirious, with an incidence of 24.3% among patients undergoing hip fracture surgery and 11.7% among those with hip replacement surgery. A predictive model for delirium included four factors: impaired hearing, passivity, low cognitive functioning, and waiting more than 18h for hip fracture surgery. Disorientation and urgent calls for attention were the most frequent behavioural changes in the prodromal phase prior to delirium. Delirium in connection with hip fracture revealed deteriorated HRQOL and cognitive functioning when measured at a six-month follow-up. The experience of being delirious was described by the patients as a sudden change of reality. Such an experience gave rise to strong emotional feelings, as did recovery from delirium. Nurses’ observations of behavioural changes in old patients with impaired cognitive function may be the first step in managing and reducing delirium. The predictive model of delirium ought to be tested further before use in clinical practice.

Le régime juridique de la société anonyme unipersonnelle (SAU) de droitOHADA est défini par renvoi au régime prévu pour la SA pluripersonnelle, avec desadaptations minimales. En réalité, le caractère unipersonnel de la SA lui confère une certaineparticularité qui rend inappropriée la transposition pure et simple des règles du modèlepluripersonnel. Outre les difficultés d’application qu’elle entraîne souvent, la technique durenvoi laisse irrésolues de nombreuses questions suscitées par l’unipersonnalité. Le régimejuridique de la SAU dans son ensemble en ressort insuffisamment adapté à l’unicitéd’actionnaire.Une adaptation du régime juridique de la SAU de droit OHADA au particularisme del’unipersonnalité devient alors nécessaire. Elle doit être entreprise sous fond de simplificationdes règles, d’une part à l’égard de la société, à travers les règles relatives à sa constitution et àson évolution, d’autre part, à l’égard des acteurs que sont l’actionnaire unique, les organesd’administration et de contrôle.Au-delà de son approche critique, l’étude a surtout pour ambition de proposer unmodèle de société anonyme unipersonnelle au régime juridique plus lisible, simple et attractif
The one-person limited company under the OHADA LAW has seen itslegal regime being defined with reference to the regime of the multi-persons limited company,with minimum adaptations. In fact the one-person character of the Limited company gives it a certain peculiarity that renders inappropriate the pure and simple transportation of rules of the multi-person limited company model. Besides the difficulty of implementation that it oftenentails, the technique of referring leaves unresolved many questions raised by the one-personlimited company model. The legal regime of the one-person limited company as a whole thatarises is insufficiently adapted to the unique shareholder.An adaptation of the one-person limited company legal regime of the OHADA LAWto the particularity of the one-person thus becomes necessary. It has to be undertaken underthe simplification of rules, on the one hand with regards to the company, through rules relatedto its constitution and its evolution, on the other hand, with respect to the actors that are thesole shareholders, administrative and control bodies

碩士
輔英科技大學
護理系碩士班
101
As our country has entered the aging society, the proportion of the elderly population using medical resources has been gradually increasing. However, sleep problems are often prevalent pressure source in ICU. An ICU patient’s probability of occurrence of acute confusion is higher than that of a general inpatient. Currently, there is a lack of research, exploring the relevance of relationship between quality of sleep and acute confusion in an ICU in Taiwan. Accordingly, this triggers the motivation to explore it. This study aims to investigate the quality of sleep of elderly patients in the SICU, the incidence of acute confusion, the related factors and predictors of acute confusion. A descriptive correlational design was adopted. This study recruited patients, who aged 65 years or more and were transferred to ICU after the surgery and had been in ICU for more than 24 hours as subjects, totaling 136 people. The results showed that 88.24 percent of SICU patients had poor sleep quality one month before the surgery. Within 5 days after the surgery, there was an average of 4.40 hours of sleep at night. The average of nighttime sleep disruption was 8.79 times within five days after the surgery. The incidence of acute confusion was 79.41% and the incidence was the highest after one day of ICU stay, accounting for up to 33.1% of the population. The predictor of acute confusion was catheterization p-value, which was 0.004 （OR, 13.465）. The age p-value was 0.006 （OR, 1.203）. The pain index p-value was 0.006 （OR, 2.547）. PSQI score p-value was smaller than 0.001 （OR, 1.823）. These four variables are statistically significant and therefore can be the predictor for SICU elderly patients with acute confusion （R2 = 0.489）. It is hoped that this study can be used in clinical practice for early detection of high risk of acute confusion to prevent further damage so that ICU nurses can establish a care model that ensures sleep quality to prevent risk factors of acute confusion and improve the quality of elderly health care.

Acute confusion is a common complication of hospitalization in the elderly that contributes to the mortality and morbidity of this patient population. Although elderly individuals admitted to hospital with an orthopaedic condition consistently present with numerous risk factors associated with the development of acute confusion, not all develop the condition. The purpose of this prospective, descriptive, correlational study was to determine if there are specific patient characteristics and environmental variables associated with the development of acute confusion in elderly patients admitted to hospital with an orthopaedic condition, and if these factors could distinguish those elderly patients who become acutely confused from those who do not. Miller's Functional Consequences Theory (1990) provided a framework for examining the etiology of acute confusion in this population. A non-probability convenience sample of 41 subjects participated in the study. Participants received serial assessments of their cognitive status using the Folstein Mini- Mental State Exam (1975), the Clinical Assessment of Confusion - A (revised) (1990), and the Visual Analogue Scale - Confusion (1986). A determination of the occurrence of acute confusion was based on a predetermined change in score on all three assessment tools used. Fourteen (34%) of the participants developed acute confusion during the first week of hospitalization. Factors significantly associated with the development of acute confusion included: admission to a particular ward, a higher emotional stress score, a higher level of dependency prior to admission, a pre-existing cognitive impairment, and a primary diagnosis of fracture. The findings of this preliminary study support a multiple factor etiology for acute confusion within this patient population. Elderly patients admitted to hospital may have common pre-existing psychosocial risk factors that put them at risk for the development of acute confusion regardless of their physiologic risk. In addition, the findings suggest that the experience of an unplanned event, such as a hip fracture may be a differentiating characteristic of patients who develop acute confusion within the general orthopaedic patient population.

碩士
國立陽明大學
臨床護理研究所
104
The purposes of this study were twofold: (1) to explore trends of pain, anxiety, and acute confusion at pre-operative period (T1), 24 hours within post-operation (T2), and 72 hours after post-operation; and (2) to discover predictors of acute confusion in patients with abdominal surgery over the pre-post operation period. A prospective, observational, repeated-measure, correlational design was adopted. Patients with abdominal surgery who admitted to intensive care unit were recruited from a medical center in the northern Taiwan. Inclusion criteria were patients aged twenty and above, and with a Richmond Agitation Sedation Scale score between -3 and +4. Results of this study were as followings. The overall incidence of acute confusion was 16.7%; and the highest incidence was 10% at T2. Using generalized estimating equation analysis, results showed that the change of pain and acute confusion were significantly different over the three time points. The highest pain score was at T2, and then it decreased at T3. The incidence of acute confusion also increased as time passed by. The change in anxiety through the pre-post operation was not significantly different. The different domains of heart rate variation were all with downward trends at T2, and then followed upward curves at T3. The predictors of acute confusion were pain, anxiety (high- and low frequency hear rate variation), age, status of consciousness, level of liver enzyme, and number of complications. Results of this study help to understand the change of pain, anxiety, and acute confusion over the pre-post operation period in patients with abdominal surgery. Recommendations from this study results are (1) to incorporate the acute confusion assessment with the routine nursing care, and (2) to monitor predictors of acute confusion in patients with abdominal surgery during their pre-post operation period.

碩士
國防醫學院
護理研究所
92
The ICU environment is a sudden stressor for critically ill patients. The stressors, severity of diseases, and other factors may precipitate the occurrence of patients’ acute confusion, especially medical and nursing intervention. When critically ill patients appear acute confusion in clinical settings, nurses just constrain them or appeal doctors to give them sedation medicine. Nurses don’t assess the factors which are related to acute confusion in time. Nurses miss the gold time to stop the bad cycle damaging patients physical and psychological states in acute confusion state. Besides, the time of weaning ventilator, the rates of reintubation and death, the needs of the medical and nursing care, the length of stay, and the cost of hospitalization would be increased when patients with acute confusion. Thus, the purpose of this study was to explore the incidence, related factors, and outcomes of acute confusion in critically ill patient intensive care units. This is a descriptive, related, and prospective study. For the convenient sampling, 484 patients were collected from the medical intensive care unit, coronary care unit, and surgical intensive care unit in one teaching hospital center in Taipei from 13th October, 2003 to 3rd March, 2004. The CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) was used to diagnose acute confusion. The data was analyzed by Chi-square, StatXact 5.0 pearson Chi-square, Mann-Whitney test, t-test, simple and multiple logistic regression, simple and multiple Cox regression. The results of the study indicated that the incidence of acute confusion is 7.44 %. The average day of incidence is 3.44 days, and the most is the first 24 hours admitted into ICU(27.8 %). The average lasting day is 2.89 days. It appears in the period of 10 p.m.-2 a.m. mostly(41.7 %). The highest incidence of acute confusion is 11.3 % in medical intensive care unit, the following is 7.5 % in coronary care unit, and 5.7 % in surgical intensive care unit, but there were no significant difference among these intensive care units. The confusion experiences, smoking, age, blood potassium level, arterial carbon dioxide level, frequency of fear, disturbed sleeping activities, severity of diseases, non-BZD sedatives, numbers of sedative, and nervousness to machine alarm were the most influencial factors. The more the length of stay and the time of using ventilator, the higher reintubation rate in critically ill patients with acute confusion. We expect the results of the study can be used to develop a tool to early detect acute confusion in order to remind doctors and nurses to prevent it. In addition, the results can be the part of contents of ICU training and contiuing education programs for the nurses working in ICU. They will increase nurses’ ability in assessing acute confusion. We recommand to study the nursing interventions early to decrease the incidence, lasting time, and severity of comorbidity of acute confusion in ICU patients. And according to the results, we can establish an ICU care protocol to prevent acute confusion in the future.

碩士
輔英科技大學
護理系碩士班
100
Objective: The current studies of acute confusion indicated that there was a phenomenon of acute confusion existing in 16%~85% of the patients in the intensive care units. Nevertheless, 78% of the patients having symptoms of acute confusion had not been identified by doctors and nurses yet. Thus the aim of the study was to explore nurses’ behaviors of caring the patients with acute confusion in the ICUs. Method: The triangulation was adopted in this study and the purposive sampling was used to recruit 10 nurses and 30 patients with acute confusion in the surgery and medicine ICUs of a southern military hospital. Result: The results of the study indicated that the incidence of acute confusion is 4.55%. The rate of the next day after the patients were sent to the ICUs was 36.6% which ranked the highest. The average age of the patients with acute confusion was 73.2 and the rate of more than 65 years old was 66.7%. The main ways of caring that the nurses used were offers of tranquilizer and physical restraints. The factors of influencing nurses’ behaviors of caring the patients with acute confusion in the ICUs were lack of nursing knowledge of acute confusion, work hours and manpower pressure, the consensus of doctors and nurses, medication, and issues of physical restraints. Conclusion: The findings of the study referred to the bottlenecks which the nurses might encounter while taking care of the patients with acute confusion and relevant improvements were further provided. Therefore, this study could be a reference for nursing practice, nursing administration and nursing research. By means of the study, the nurses’ abilities of both anticipating and caring the patients with acute confusion could get strengthened and the hurts caused by acute confusion which might be incident to patients in the ICUs could get reduced. In the meantime, the satisfaction which the patients and their family expressed at the nurses’ quality of caring would be upgraded.

Research Doctorate - Doctor of Philosophy (PhD)
The study presented in this thesis provides a description and interpretation of the experiences of family members during their older loved one’s delirium. Fourteen women, aged 51 to 74 years, participated in the study and, over an interview period of nineteen months, described their experiences. These twelve daughters and two wives supported and cared for their loved one at home, in residential aged care and/or while hospitalised. The approach used to explore the women’s experiences was existential phenomenology, informed by the philosophies of Sartre and Merleau-Ponty. Changing family portraits: Sudden existential absence during delirium depicts the women’s experiences during their older loved one’s delirium. Existential absence for these women was experienced as the sudden absence of their familiar older loved one and the arrival of a stranger.The meaning of existential absence is further represented by the theme Living the fragility of a loved one’s presence and the sub-themes Facing a loved one's existential absence and Living with a stranger, as well as the theme Living life holding on and the sub-themes Waiting for a loved one, In the dark, On the fringe but centre stage, On thin ice, and Keeping secrets. These themes describe the unexpected and distressing nature of their loved one’s absence during delirium, and how difficult it was for the women to cope and await their loved one’s return. The description and interpretation presented in this thesis reveals the profound impact of family member experiences during their older loved one’s delirium. It establishes the importance of health care staff appreciating family member experiences and relates the insights gained to health care practice, suggesting how family member experiences can inform ways health care staff include family members in their older person’s care and provide compassionate, sensitive support during delirium.

Acute confusional state (ACS) or delirium according to DSM-III-R holds a central position in the medicine of old age. ACS is a common and sometimes the only symptom of diseases and medical complications in the elderly patient. The aim of this study was to elucidate ACS in patients with femoral neck fractures and patients with acute stroke with regard to frequency, predictors, possible pathogenetic mechanisms, associated complications, assessment and documentary routines and the clinical outcome for the patients. An intervention program to prevent postoperative ACS based on our results was developed and evaluated. The main findings of the study were high frequencies of ACS in elderly patients with femoral neck fractures (61 %) and in patients with acute stroke (48 %). The main risk factors for ACS in patients with femoral neck fractures were old age, diseases and drug treatment interfering with cerebral cholinergic metabolism. There was no link between anaesthetic technique and ACS but the connection between peroperative hypotension, early postoperative hypoxia and ACS was close. In stroke patients the degree of extremity paresis and old age were independent ACS risk factors. ACS was commonly associated with post stroke complications such as myocardial infarction, pneumonia, urinary infection and urinary retention. In stroke patients there was a close connection between high hypothalamic-pituitary-adrenal axis (HPA-axis) activity and ACS. High HPA-axis activity and disturbances in the cerebral cholinergic system may be two important ACS mechanisms. A correct diagnosis is a prerequisite for proper treatment of ACS and its underlying causes. In the orthopaedic wards both physicians and nurses diagnosed and documented ACS poorly and therefore associated complications were insufficiently treated. The intervention program for postoperative ACS, aimed mainly at protecting the cerebral oxidative metabolism and thereby the cerebral cholinergic metabolism which is especially sensitive to hypoxia. Postoperative complications associated with ACS were also treated. The intervention resulted in reduced frequency, duration and severity of postoperative ACS and in shorter orthopedic ward stay for patients with femoral neck fractures.Key words: Acute confusional state, delirium, elderly

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Les personnes âgées occupent une proportion importante des lits dans les centres hospitaliers de soins de courte durée québécois et leur présence est en augmentation. Parmi ces personnes, plusieurs présentent un état confusionnel aigu (ÉCA), voire un délirium, au cours de leur hospitalisation. Les soins infirmiers qu’elles requièrent sont complexes et les études portant sur la formation continue des infirmières tiennent peu compte de cette réalité. Les approches utilisées dans les études sont surtout centrées sur l’acquisition de connaissances et d’habiletés techniques et négligent les aspects créatifs, relationnels, critiques, réflexifs et éthiques essentiels à une prestation de soins infirmiers de qualité. On y retrouve également peu d’informations sur la conception de l’intervention éducative et sur son évaluation. C’est dans cette perspective que le but de l’étude était de mettre à l’essai et d’évaluer qualitativement le processus et les résultats d’une intervention éducative auprès d’infirmières soignant des personnes âgées hospitalisées en ÉCA. Plus particulièrement, ce sont les conditions facilitant et contraignant l’intervention, les aspects les plus utiles pour la pratique, les différents savoirs exprimés et les résultats de soins perçus par les participantes qui étaient recherchés. C’est en s’inspirant de la pédagogie narrative de Diekelmann (2001) et des savoirs infirmiers de Chinn et Kramer (2008) que l’intervention a été conçue et évaluée. La description d’expériences de soins vécues par les infirmières et la création d’un environnement d’apprentissage favorisant l’interprétation, en groupe, de ces expériences à l’aide d’informations théoriques et empiriques caractérisent la pédagogie narrative à la base de cette intervention. Pour atteindre le but, une étude de cas a été retenue. La stratégie d’échantillonnage par choix raisonné a permis de sélectionner des participantes travaillant sur les trois quarts de travail, ayant différents niveaux de formation et une expérience comme infirmière variant de huit mois à 36 ans, dont l’âge variait de 23 à 64 ans. L’échantillon, composé de 15 infirmières soignant fréquemment des personnes en ÉCA et travaillant sur des unités de soins chirurgicaux cardiologiques et orthopédiques, était réparti dans trois groupes égaux de cinq participantes. L’intervention éducative comprenait quatre journées de formation offertes à intervalle de trois semaines pour une durée totale de 12 semaines. Au cours de chacune de ces journées, les participantes devaient effectuer un travail écrit réflexif concernant une situation de soins vécue avec une personne en ÉCA et, par la suite, partager, interpréter et s'interroger sur ces situations en faisant des liens avec des informations théoriques et empiriques sur l’ÉCA dans le cadre d’un atelier de groupe. Une triangulation de méthodes de collecte de données, incluant des notes de terrain de l’investigatrice, les travaux réflexifs des participantes, des questionnaires complétés par les participantes après chaque journée de formation et une entrevue individuelle avec chaque participante réalisée par une intervieweuse externe à la fin de l’intervention, a permis de décrire la mise à l’essai de l’intervention et d’évaluer qualitativement son processus et ses résultats. Une analyse de contenu des données qualitatives intra et inter participante a été effectuée. La mise à l’essai de l’intervention a mis en évidence l’importance de tenir compte des besoins variés des participantes et d’ajuster l’intervention éducative d’un groupe à l’autre, notamment eu égard aux contenus théoriques et empiriques sur l’ECA. L’évaluation du processus souligne que l’intervention a été facilitée par les attitudes et la diversité des expériences des participantes, ainsi que par l’utilisation de situations de soins réelles permettant d’intégrer la théorie dans la pratique. L’accès à de nouveaux outils d’évaluation des personnes en ÉCA a été perçu particulièrement utile par les participantes. Quant à l’évaluation des résultats, elle a permis de rendre visibles de nombreux savoirs empiriques, éthiques et esthétiques et certains savoirs personnels et émancipatoires exprimés par les participantes. Les participantes ont, entre autres, réalisé des évaluations plus approfondies des personnes en ÉCA, ont réduit ou évité les mesures de contrôle physiques des personnes atteintes et ont impliqué davantage les familles dans les soins. L’évaluation a aussi permis de décrire certains résultats perçus par les participantes sur le bien-être physique et psychologique des personnes soignées et sur les familles. Les personnes en ECA étaient, entre autres, rassurées, plus calmes et soulagées et les familles moins inquiètes et davantage impliquées dans les soins. Les résultats de l’étude mettent en évidence l’applicabilité d’une intervention éducative narrative basée sur un cadre de référence en sciences infirmières et son utilité pour la formation continue dans les milieux de soins. L’étude ouvre la porte à des possibilités de transfert de l’intervention à d’autres populations d’infirmières soignant des clientèles ayant des besoins complexes, notamment en gériatrie, en oncologie ou en soins palliatifs. Des études visant à évaluer l’intervention auprès d’un échantillon plus important et à explorer ses effets sur les personnes soignées et leurs familles sont proposées.
Older persons occupy a growing proportion of the beds in Quebec short-stay hospitals. Many of these persons present acute confusional state (ACS), or delirium, in the course of their hospitalization. The nursing care that they require is complex but studies show that continuing nursing education takes scant account of this reality. The approaches used in these studies have focused above all on the acquisition of knowledge and technical skills and have neglected the creative, relational, critical, reflexive and ethical aspects essential to delivering quality nursing care. In addition, these studies contain little information relative to the design of pedagogical interventions and their evaluation. Against this background, a study was undertaken aimed at field-testing and qualitatively evaluating the process and results of a pedagogical intervention for nurses who care for hospitalized older persons with ACS. The focus was more specifically on identifying the facilitating and constraining conditions to learning, the aspects most useful to practice, the different types of knowledge expressed, and the care outcomes perceived by participants. Inspiration for the design and evaluation of the intervention was drawn from the narrative pedagogy approach developed by Diekelmann (2001) and the various patterns of knowing knowledge defined by Chinn and Kramer (2008). The narrative pedagogy at the root of this intervention consists essentially of describing the lived care experiences of nurses and creating a learning environment conducive to group interpretation of these experiences based on theoretical and empirical data. To achieve the objectives, a case study design was used. Purposive sampling allowed selecting participants working all three work shifts, possessing different levels of training, boasting nursing experience ranging from eight months to 36 years, varying in age from 23 to 64 years. The sample, composed of 15 nurses who worked on cardiac and orthopedic surgery units and who often cared for persons with ACS, was divided into three equal groups of five. The pedagogical intervention comprised four days of training offered at an interval of three weeks for a total duration of 12 weeks. On each of these days, participants had to complete a written reflexive exercise regarding a lived care situation involving a person with ACS and then, in the context of a group discussion, share, interpret and question these situations by drawing connections with available theoretical and empirical data on ACS. A triangulation of data collection methods, including the investigator’s field notes, the participants’ written reflexive exercises, questionnaires completed by the participants after each day of training, and individual interview with each participant carried out by an outside interviewer at the end of the intervention, allowed describing the field-testing of the intervention and qualitatively evaluating its process and results. The qualitative intra and inter-participant data was then subjected to content analysis. Field-testing of the intervention highlighted the importance of taking account of the varied needs of the participants and to adjust the pedagogical intervention from one group to the next, particularly with respect to the theoretical and empirical content on ACS. Process evaluation underscored that the intervention was facilitated by the attitudes and the diversity of experiences of the participants, as well as by the use of real care situations, which allowed integrating theory in practice. Access to new tools for assessing persons with ACS was perceived to be particularly useful by the participants. As for the results evaluation, it allowed revealing various types of knowledge, including of the empirical, ethical and esthetic sort, but also some personal and emancipatory knowledge expressed by the participants. Moreover, the participants performed more in-depth assessments of persons with ACS, reduced or avoided the use of physical control measures on these persons, and involved families more in care. The evaluation also allowed documenting some of the effects perceived by the participants on the physical and psychological well-being of care recipients and their families. Persons with ACS were reassured, calmer and soothed, among other things, while families were less worried and more involved in care. The study’s results evidence the applicability of a narrative pedagogy intervention based on a nursing frame of reference and its utility in continuing education in the field of care. The study opens up the possibility of transferring the intervention to other populations of nurses who tend to clienteles with complex needs, particularly in geriatric, oncological and palliative care. It is proposed that future studies evaluate the intervention on a larger sample and explore its effects on the persons cared for and their families.