Unreal experiences: clinical advice for the care of patients with post-operative confusion.

Key words: Clinical advice *delirium *intensive care *post-operative confusion

SUMMARY

* Post-operative confusion is a relatively common and well-known condition in patients who are treated in intensive care units. As many as 72% of all patients who are treated in intensive care exhibit signs of confusion. It is a psychosis-like condition in which patients can have difficulty in co-ordinating thought and speech, in orientating themselves in time and space, and in receiving and processing information.

* Some patients can have occasional unreal experiences. Suspicion, fear, anxiety and aggressive behaviour can develop. Certain patients become euphoric whereas others exhibit passive behaviour.

* Signs of post-operative confusion can develop two or three days after the patient's arrival in the intensive care unit and can last for several weeks. The nurse is often the first person who notices the patient's confusion. However, the nurse, together with other members of the healthcare staff may be indaequately experienced to identify and treat the various stages of confusion.

* This article describes a project to produce clinical advice for intensive care nurses regarding the care of patients with post-operative confusion, based on scientific literature and practical experience.

BACKGROUND

Post-operative confusion, which may lead to unreal experiences (hallucinations), is a relatively common and well-known condition in patients who are treated in intensive care units (ICUs). The incidence is undefined but has been reported to vary between 7% and 72% (Granberg et al. 1996). When patients exhibit signs of confusion, they find themselves in a psychosis-like condition and can have difficulty in coordinating thought and speech, in orientating themselves in time and space, and in receiving and processing information (Granberg-Axell et al., 2001).

"Unreal experiences" are phenomena which appear in an experienced total wakeful condition or in a condition between wakefulness and sleep; they are experienced as real, and can appear at any time. They tend to appear more frequently in the evening or at night when the patient tries to sleep (Granberg-Axell et al., 2001). Suspicion, fear, anxiety and aggressive behaviour can develop. Certain patients become euphoric whereas others exhibit passive behaviour. Signs of post-operative confusion can develop two or three days after the patient's arrival at the ICU and can last for several weeks (Granberg et al., 1999).

There are three main reasons to prevent delirium; it causes higher mortality, longer stay and higher cost. For example, in a study by Ely et al. (2004) despite similar baseline characteristics in a cohort of 275 mechanically ventilated patients, delirium was an independent predictor of higher six-month mortality and was also the strongest independent determinant of length of stay in the hospital.

EXPERIENCES OF TEMPORARY CONFUSION

Fagerberg and Jonhagen (2002), in their phenomenological study of older people, found that the most common feeling when experiencing temporary confusion, was the experience of threat. For example, one of the informants in their study stated:

   "Yes I was so afraid, I feared for my life because I was the
   only one that knew that we were to be invaded by this
   other nation. They had told me that and all I wanted was to
   let the staff know this but it was impossible to get them on
   my side. I could not succeed no matter how hard I tried."
   (Fagerberg & Jonhagen, 2002, p.341)

Other themes were suspiciousness, wide-open senses and a need to escape, as demonstrated in the following example:

   "I was in bed looking up at the ceiling and the lamps were
   moving across towards me, and I thought "it's coming over
   me". Yes, I was so afraid but there was nothing I could do
   to stop it from coming closer and affecting me so I went
   over to the other bed and lay down there."
   (Fagerberg & Jonhagen 2002, p.343).

The experience of being temporarily confused was described as something the patient felt ashamed of and it brought on a sense of guilt. The feeling of guilt was experienced as a burden when realising that others had observed him or her when he or she was in his or her confusional state. In retrospect it was common that the patient felt regretful over what had happened (Fagerberg & Jonhagen 2002).

In a qualitative PhD study using interviews and observation to collect data in an orthopaedic surgery setting, patients described anger, fear, insecurity and panic as strong emotional feelings that were connected with their experiences during delirium (Sorensen Duppils, 2003). They were ready to fight with the staff to get away from those feelings. Patients also associated the entry into delirium with some unfulfilled basic needs, for example freezing and thirst. Some patients could describe exactly what happened when they entered into delirium. One man said:

   " ... it began with an enormous thirst ... it was like fire in
   my throat, my tongue was stuck up against my palate and
   then the nightmares began." (Sorensen Duppils, 2003,
   paper III, p.5).

Patients described their experience of being postoperatively confused as if they were in a dream at the same time as they were awake. Sometimes patients experienced difficulty in communicating with others during delirium. For example, one informant stated:

   "I tried to get in contact with the others, but I could not
   reach them. I do not know if the nurses realised that I
   was an outsider, they talked with each other and I did not
   understand what they wanted of me."
    (Sorensen Duppils, 2003, paper III, p.7).

One woman said that she argued loudly, but not sucessfully, with the nurses to escape the injection that she thought was going to kill her:

   "I do not want that injection", I said. But they did not
   care... they smiled and were so friendly. But I saw through
   them, I knew that they were only pretending to be friendly
   so I would not smell a rat."
    (Sorensen Duppils, 2003, paper III, p.7).

In an observational study of intensive care patients during weaning from mechanical ventilation, some patients reported that the unreal experiences they felt while being confused became aggaravated when they were trying to sleep. Other patients said they were afraid to go to sleep because they thought they would die while sleeping (Granberg Axell, 2001).

RECOGNITION OF POST-OPERATIVE CONFUSION

The nurse is often the first person who notices the patient's confusion. However, the nurse, together with other members of the healthcare staff, is reported to be ill-prepared to identify and adequately treat the various stages of confusion (Litton, 2003).

The most important step in delirium management is early recognition. Once delirium is detected, efforts should focus on identifying the aetiology. This can be done by assessing for the presence of known risk factors. Strategies for the prevention and management of delirium in the ICU are considered to be important areas for future investigation (ICU Delirium and Cognitive Impairment Study Group, 2006a).

CLINICAL ADVICE

The objective of our project was to produce an action plan dealing with the care of patients with post-operative confusion. The plan was to be based on scientific literature and practical experience from psychiatry and intensive care. The action plan that we developed consists of clinical advice for nursing staff and an information booklet for patients and relatives affected by the condition. (A copy of the information booklet may be obtained from the authors on request.)

This article describes the clinical advice in detail. Based on our examination of the published literature, as well as our own clinical experience, we developed clinical advice which we divided into three areas:

* preventative measures,

* what can be done once the patient has developed post-operative confusion,

* what ought to be considered after an incident of post-operative confusion.

Nursing interventions are intended to increase both the patient's cognitive status and his or her sense of security and well-being.

Preventative measures

The nursing staff's role is first and foremost to prevent post-operative confusion by identifying its early signs. These include anxiety, restlessness, irritation and sleep disturbance. If the signs are not noticed and acted upon in time patients risk developing agitation and total confusion. The preliminary stage of an episode of postoperative confusion can last l-3 days. In an acute phase, where the patient is agitated and aggressive, the use of sedatives may be a necessity but the primary course of treatment is always to prevent and eliminate the underlying causes of confusion. The following clinical advice was developed (Table 1):

Intervention in cases of post-operative confusion

The matter of primary importance is to treat the underlying causes. If, for example, the post-operative confusion is as a result of the medication used, cease its use if possible. If it is as a result of lack of sleep then see to it that the patient gets the sleep he or she needs. If insufficient pain relief is the cause then give pain relief so that the patient's estimation of the level of pain experienced (rated on a visual analogue scale of 0-10, where 10 is greatest pain) is less than 3.

The following advice is given (Table 2):

After post-operative confusion

The following actions are suggested:

* Many patients have unpleasant memories after their stay in hospital. These should be discussed with the patient afterwards.

* Give both the patient and his or her relatives a copy of the information booklet entitled "For those of you who have had unreal experiences during the period of your medical care on ward 50B".

CONCLUSIONS

In today's health service nursing staff often fail to notice that patients are entering an acute state of confusion and it is first noticed when the patient is agitated or confused. When the patient becomes agitated or paranoid he or she may need to be sedated, which can lengthen the time spent in ICU and thereby increase the risk for complications.

Early detection of post-operative confusion is important to be able to provide adequate treatment and care. It is therefore important that the nurse learns to recognise the symptoms in order to start (preventative) treatment/nursing interventions.

Evidence-based clinical advice provides an opportunity to assure the quality both of the preventative nursing as well as that of nursing and treatment in instances of post-operative confusion. The nursing period can be shortened and the patient guaranteed more secure nursing care. It has become apparent that there is a large need for information concerning post-operative confusion felt both by those who have been directly affected by unreal experiences, that is the patient, and those who have been indirectly affected, that is their relatives. An information booklet based on evidence can provide a good support for the patient and his or her relatives when it comes to understanding what has happened.

An action plan based on evidence forms a stable basis for the suggested measures. A caregiver who works in accordance with a rational theory has a frame of reference on which to base his or her opinions. It is our hope that this work can contribute to the better nursing of patients suffering from post-operative confusion.

Later this year our ICU will be focusing on the problem of postoperative confusion. We intend to assess all of our patients three times per day, using the Confusion Assessment Method for the ICU CAM-ICU), which is a delirium monitoring instrument for ICU patients (ICU Delirium and Cognitive Impairment Study Group, 2006b). Using this tool we hope to identify objectively which of our patients are confused, those who are on their way to being confused, or those who have had unreal experiences that we have not noticed.

REFERENCES

Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Inouye SK, Bernard GR, Dittus RS. (2004).Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291 (14), 1753-1762.

Fagerberg I, Jonhagen ME. (2002). Temporary confusion: a fearful experience. Journal of Psychiatric and Mental Health Nursing 9 (3), 339-346.

Granberg-Axell A, Bergbom I, Lundberg D. (2001). Clinical signs of ICU syndrome/ delirium: an observational study. Intensive and Critical Care Nursing 17(2), 72-93.

Granberg A, Engberg BI, Lundberg D. (1996). Intensive care syndrome: a literature review. Intensive and Critical Care Nursing 12 (3), 173-182.

Granberg A, Engberg BI, Lundberg D. (1999). Acute confusion and unreal experiences in intensive care patients in relation to the ICU syndrome. Part II. Intensive and Critical Care Nursing 15 (1), 19-33.

ICU Delirium and Cognitive Impairment Study Group (2006a). Brain Dysfunction in Critically Ill Patients. [Online] available at: www.icudelirium.org/delirium (accessed September 2006).

ICU Delirium and Cognitive Impairment Study Group (2006b). Delirium Assessment. [Online] available at: http://www.icudelirium.org/delirium/training-pages/del.assessment.html (accessed September 2006).

Litton AK. (2003). Delirium in the Critical Care Patient. What the professional staff needs to know. Critical Care Nursing Quarterly 26 (3), 208-213.

Sorensen Duppils G. (2003). Delirium during Hospitalisation. Incidence, Risk Factors, Early Signs and Patients Experiences of Being Delirious. Unpublished PhD thesis, Uppsala University, Uppsala, Sweden.

Maria Bruhn Lundblad, RN, Ward 109, Uppsala University Hospital, Sweden *Eva Johansson Hovstadius, RN, Ward 50B, Uppsala University Hospital, Sweden E-mail: [e-mail] *[e-mail]

Table 1: Preventative measures: action plan

Action                               Comments

Find out how the patient felt        Previous anxiety problems can
prior to the operation.              generate powerful post-operative
                                     confusion. Even if unease or
                                     anxiety does not appear in the
                                     patient's medical history
                                     pre-operative stress can
                                     contribute to post-operative
                                     confusion.

Find out about the patient's use     The effects of alcohol in addicts
of alcohol/coffee/tobacco.           can make themselves felt 48-72
                                     hours after the patient has been
                                     admitted to ICU. Abstinence from
                                     the use of caffeine and nicotine
                                     can lead to post-operative
                                     confusion.

Create a clear, calm and secure      Remind the patient he or she is;
environment.                         what the date and time are and
                                     explain what is taking place in
                                     his or her surroundings. Try to
                                     keep the conversation to concrete
                                     facts/phenomena in the patient's
                                     immediate environment.

Good communication.                  Good communication on the part of
                                     the carer can help the patient
                                     reduce any feeling of isolation,
                                     helplessness and fear. If the
                                     patient has problems with their
                                     sight or hearing it is important
                                     that he or she has access to the
                                     necessary technical aids.

Create a sense of security for the   Reduce unease by being close at
patient.                             hand and by the use of touch or
                                     massage. Listening to what the
                                     patient has to say and talking to
                                     them also help. Be conscious of
                                     the fact that grief, fear and
                                     anxiety can trigger post-operative
                                     confusion. The patient should not
                                     be left alone. Eye contact and
                                     touch are important in order to
                                     maintain the patient's attention
                                     in a conversation.

Prevent stress.                      Minimise the need to move the
                                     patient. Do not expose the patient
                                     to activities which can infringe
                                     on their integrity, for example,
                                     by washing him or her with the
                                     door open or in front of other
                                     patients or by loudly passing on
                                     information about the patient.
                                     Respect the patient's territory.

Prevent and treat pain.              Pain can act a complete block to
                                     sleep as well as increasing both
                                     the time taken to fall asleep and
                                     the number of times the individual
                                     wakes up thereby reducing the
                                     overall amount of sleep. Be
                                     especially attentive to patients
                                     who are sedated and/or intubated.

Plan a period of 'winding down'      Give medication so that the
before the patient's bedtime.        patient can get a good night's
                                     rest. Bear in mind that unease and
                                     sleep disturbance are strongly
                                     connected. Stimulate relaxation by
                                     the use of massage and music.
                                     Warm drinks and warm socks a
                                     peaceful effect.

Provide the opportunity for          Co-ordinate the timing of various
undisturbed, continuous sleep.       activities involving the patient,
                                     stimulate the natural diurnal
                                     rhythm, reduce the level of
                                     lighting and sound, be quiet
                                     yourself. Offer the patient
                                     earplugs and eye-shades. Place a
                                     sign on the door, stating that the
                                     patient is sleeping. Note the
                                     patient's periods of sleep on the
                                     monitoring list.

Observe whether or not the patient   Passive behavior can be an early
into 'goes into his or her shell',   sign of an incipient confusion.
no longer talks to other patients,   Utilise all activities as training
does not read newspapers et          opportunities (such as, for
cetera.                              example, in the armchair).
                                     Remember that passive behaviour
                                     can also be responsible for the
                                     patient experiencing
                                     hallucinations (seeing insects on
                                     their body or in the bed). It can
                                     also be responsible for other
                                     paranoid thoughts.

Support the patient's relatives so   Relatives and friends can a large
that they can contribute to his or   role in a good and recognisable
her feeling of peace and calm.       environment for the patient.

Ask the doctor to go over the        Look out for medication with
patient's  medication list.          anticholinergic effects
                                     (neuroleptics, antidepressants,
                                     antihistamines, furosemides). Note
                                     whether or not the patient was
                                     using benzodiazepines even before
                                     the operation--the propensity for
                                     anxiety increases if the
                                     medication is stopped abruptly.

Does the a urinary or                The infection is in itself a
respiratory tract infection?         predisposing factor for
                                     post-operative confusion.

Note and treat disturbances in       Constipation and urinary retention
intestinal/bladder function.         can be factors which trigger
                                     post-operative confusion.

Ensure that the patient has an       Patients who a lower saturation
adequate arterial oxygen             and haematocrit values more often
saturation (> 95%, with              fall victim to serious
haematocrit > 30%).                  post-operative confusion than
                                     those with or higher values for
                                     saturation and haematocrit.

Note whether or not the patient      A low blood pressure can lead to
has had periods of low blood         changes in the brain's blood
pressure (in connection with blood   perfusion and blood oxygen level,
loss, lack of fluid).                which in turn can trigger
                                     post-operative confusion.

Normalise electrolyte and fluid      Electrolyte imbalances together
balance.                             with dehydration and the
                                     simultaneous use of diuretics are
                                     a common cause of post-operative
                                     confusion.

Ensure that the patient has normal   Hypoglycaemia can contribute to
glucose levels.                      post-operative confusion.

Table 2: Intervention measures: action plan

Action                               Comments

Acknowledge the patient's feelings   Try to give the patient a firm
but ignore the confused element in   link with reality.
what he or she may say.

Bear in mind that any attempt to
force the patient to do or accept
something may increase the
patient's fear and with it his or
her agitation.

Administer medication as and when    Suitable medication for use in
needed.                              cases of post-operative confusion,
                                     and in the promotion of sleep or
                                     the reduction of a feeling of
                                     unease is presented in a separate
                                     directive.

At the slightest suspicion of the    Check even those medicines which
influence of on the confused state   the patient was taking prior to
of the patient ask the to go         being admitted to the ICU.
through the patient's medication
list and remove any unnecessary
items.

In extreme conditions the use of     Where possible try to prevent the
compulsory care procedures may be    patient leaving the ward.
considered (consult a doctor).