SCREENINGS
1. Level of alertness –
2. Orientation –
3. Attention –
4a. Change in thinking or behavior?
4b. Any hallucinations or paranoia?
WHAT ARE KEY STEPS IN 4AT DELIRIUM SCREEN
BEFAST (spell it out)
What is Balance, Eyes, Face, Arm, Speech % Time
A clinical syndrome that may be caused by medical conditions, infections, substance intoxication or medication side effects. It is characterized by an altered level of consciousness, disorientation and decreased ability to focus or sustain attention that develops acutely.
What is Delirium
Diagnostic test used to pinpoint the location of a tumor, infection or brain bleed.
CT scan
• Disoriented • Agitated • Lethargic • Drowsy and difficult to arouse • Unable to follow commands
What are commons signs and symptoms of Delirium
PERRLA
What is pupil assessment
Neuroglycopenic signs and symptoms are signs and symptoms that result from direct central nervous system (CNS) deprivation of glucose. These include behavioral changes, confusion, dizziness, headache, fatigue, seizure, coma, and potential death if not immediately corrected
What is hypoglycemia.
First line treatment for ischemic stroke
What is thrombolytic therapy
patient fall risk evaluation tools used in inpatient healthcare
What is Hester Davis
Correctly state their name, location and circumstances
What is orientation
Blockage in a blood vessel, resulting in a restricted blood supply to the brain
What is ischemic stroke
Pair of test to determine how fast you blood clots
What is PT and PTT
Critical times to screen for delirium..
What is on admission, every shift, and change in condition.
Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems.
What is a Focused assessment
Portable diagnostic tool utilized to differentiate hypoglycemia vs stroke
What is point of care
Important multidisciplinary consults in stroke post-stroke
What are PT, OT, and speech consults
Hoarseness, throat clearing, drooling, aspiration are signs
What is dysphagia