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Delirium superimposed on dementia: accuracy of nurse documentation
Melinda R Steis1, Donna M Fick
1Department of Veterans Affairs Medical Center, Tampa, FL, USA. Melinda.Steis@va.gov
Journal of Gerontological Nursing
|July 19, 2011
Summary
Nurses caring for dementia patients experiencing delirium often documented symptoms like confusion and restlessness but not delirium recognition. Improved education and support are needed for early detection and treatment of delirium in this vulnerable population.
Area of Science:
- Gerontology
- Nursing Science
- Cognitive Impairment Research
Background:
- Delirium is an acute confusional state with poor outcomes in older adults.
- Dementia complicates the course of delirium, presenting unique care challenges.
- Accurate documentation is crucial for understanding and managing patient care.
Purpose of the Study:
- To analyze nursing documentation for patients with dementia and co-occurring delirium.
- To identify how nurses describe symptoms associated with delirium in this population.
- To assess the extent to which delirium is explicitly recognized in nursing notes.
Main Methods:
- A retrospective review of 128 days of clinical documentation.
- Analysis of nursing notes for patients with a diagnosis of dementia experiencing delirium.
- Qualitative assessment of descriptive terms used by nurses.
Main Results:
- Nurses did not consistently document the recognition of delirium.
- Commonly documented terms included fluctuating mental status, lethargy, confusion, negative behavior, delusions, and restlessness.
- The documentation focused on symptoms rather than the explicit diagnosis of delirium.
Conclusions:
- Nurses require enhanced education on delirium recognition in dementia patients.
- Clinical and decision-making support is necessary for nurses to identify and treat delirium effectively.
- Addressing underlying causes of delirium is critical for improving outcomes in older adults with dementia.
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
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Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:26Guidelines for Nursing Documentation II
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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01:10Documentation of Nursing Diagnosis
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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01:06Legal Guidelines for Documentation
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It typically involves three columns for recording information:
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01:20Introduction to Documentation and Reporting
Documentation is the systematic process of formally recording, maintaining, and communicating information.
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