A newer tool that allows bedside nurses to assess patients' cognition that does not require specific training is the AWOL. The AWOL is easy to learn and requires very little time to administer and chart. It is primarily useful in identifying those at risk for cognitive impairment (see Table 2). In a study by Douglas et al. (2013) among patients with an AWOL score of 2–4, the risk of developing delirium was 25% (positive predictive value), compared with 3.0% for those with a score of 0–1 (negative predictive value, 97%); p< .001 using Fisher's exact test. The AWOL correctly classified 17 of the 28 patients (61% sensitivity) who developed delirium in the cohort. Specificity was 87%.
Use of an assessment tool can easily be incorporated into the admission interview process. The ideal environment to conduct this initial assessment is in a quiet room, without distractions (e.g., close the door and turn off the television/iPad/iPhone, etc.). General guidelines for the assessments include the following: (1) Make sure the patient can see and hear you. If the patient uses hearing aids or wears glasses, these should be in place at the time of each assessment; (2) Do not give verbal praise or indicate correct or incorrect answers (you may want to ask any family present to leave the room); and (3) Document exactly what you see and hear; do not interpret behaviors. Be very specific in your descriptions. Instead of patient disoriented, write patient stated she was atop the Eiffel Tower; and rather than writing patient inattentive, write patient easily distracted by noises (Marcantonio, 2017).
Continuing orientation is the process of frequently orienting a person at risk for cognitive impairment and delirium to time, person, and place to keep the patient from becoming disoriented. It differs from reorientation as it should begin on admission before any signs of disorientation appear. Disorientation is an altered mental state. A person who is disoriented may not know his or her location and identity or the time and date. The patient may think that it is nighttime during the day, may climb into the wrong bed, or eat from another patient's tray. They may also wander.
Orientation to time has been reported to be one of the most efficient measures for discriminating between those with and without delirium and in predicting cognitive decline (Lou, Dai, Huang, & Yu, 2003). Failure to identify the year correctly was reported as the single most valuable sign of cognitive impairment, combining high sensitivity (95%) and specificity (86.5%; O'Keeffe, Mukhtar, & O'Keeffe, 2011). In a stepwise logistic regression, not knowing the year (odds ratio [OR]: 37.2 [95% CI: 13.1-101.3]), not knowing the month (OR: 3.85 [CI: 1.43-10.38]), and an error of 1 hour or more in time of day (OR: 2.76 [CI: 1.0-7.46]) were independent predictors of cognitive impairment (O'Keeffe et al., 2011).
Early mobilization is getting the patient out of bed to sit in a chair and/or walk around the nursing unit as close to the time of surgery as possible. Originally used to reduce the risks associated with bed rest, the beneficial effects of early mobility now include shorter duration of delirium and reduced postoperative complications (Schweickert et al., 2009) and reduction in length of stay (Muehling et al., 2009; Muller et al., 2009) and mechanical ventilation days (Schweickert et al., 2009), thus lowering overall costs. In a study of intensive care unit patients, early physical and occupational therapy led to reduced incidence and duration of delirium, less days intubated, and a more likely return to independent functional status at discharge (Guerra, Parminder, Singh, & Taylor, 2015).
Strategies for early mobilization and socialization protocol include the following:
Primary prevention is the most effective strategy to maintain cognition and prevent delirium. To decrease the incidence of delirium, keep patients safe, maintain their functionality, or plan for safe discharge to their original place of residence, all older adults admitted for orthopaedic surgical procedures should be cared for using a cognitive impairment bundle. Up to 24% of patients undergoing any orthopaedic procedure experience delirium and its associated cognitive impairment. Patients with a hip fracture are the most vulnerable of the orthopaedic surgery population as the incidence of delirium is the most frequently reported postoperative complication in this group.
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For additional continuing nursing education activities on orthopaedic nursing topics, go to nursingcenter.com/ce.