Browse > Article
http://dx.doi.org/10.17703/IJACT.2019.7.1.112

Evaluation of Nursing Documentation of Delirium Care  

KANG, Yun (College of Nursing, Taegu Science University)
Publication Information
International Journal of Advanced Culture Technology / v.7, no.1, 2019 , pp. 112-121 More about this Journal
Abstract
The purpose of the study was to determine whether a delirium educational program has a positive outcome on nurses' documentation in patient records of delirium care. A one group pre-post design was used. A convenient sample of 60 consecutive records that included documentation by participating nurses in four medical wards of one regional general hospital in South Korea was audited two months before and two months after a delirium educational program. Although an educational program in this study positively changed nurses' knowledge and attitudes, these positive effects did not translate to improvement in the documentations of delirium care. There was no significant increase in the frequency of nursing documentation of delirium assessment following participation in the educational program. Furthermore, there was no significant increase in the frequency of nursing documentation of the use of non-pharmacological management following the documentation of keywords associated with delirium after participation in the educational program. The findings indicate the need to develop, implement and record a systematic risk assessment for delirium and assessment and management of existing delirium based on evidence-based guidelines in clinical practice in South Korea.
Keywords
Delirium; Evaluation; Nursing; Documentation; Care;
Citations & Related Records
연도 인용수 순위
  • Reference
1 D. Fick, A.M Kolanowski, J.L. Waller, S.K. Inouye,"Delirium Superimposed on Dementia in A Community-Dwelling Managed Care Population: A 3-Year Retrospective Study of Occurrence, Costs, and Utilization," The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, Vol. 60, No. 6, pp. 748-753, 2005.   DOI
2 D.L. Leslie, S.K Inouye,"The Importance of Delirium: Economic and Societal Costs," Journal of the American Geriatrics Society, Vol. 59, No. 2, pp. S241-S243, 2011.   DOI
3 J.S. Partridge, F.C. Martin, D. Harari, J.K. Dhesi, "The Delirium Experience: What Is The Effect on Patients, Relatives and Staff and What Can Be Done to Modify This?," International Journal of Geriatric Psychiatry, Vol. 28, No. 8, pp. 804-812, 2013.   DOI
4 D. Fick, D.M. Hodo, F. Lawrence, "Recognizing Delirium Superimposed on Dementia - Assessing Nurses' Knowledge Using Case Vignettes," Journal of Gerontological Nursing, Vol. 33, No. 2, pp. 40-47. 2007.
5 S.K. Inouye, "Current Concepts - Delirium in Older Persons," The New England Journal of Medicine, Vol. 354, No. 11, pp. 1157-1165. 2006.   DOI
6 M.R. Steis, Fick D. "Delirium Superimposed on Dementia: Accuracy of Nurse Documentation," Journal of Gerontological Nursing, Vol. 38, No. 1, pp. 32-42, 2012.   DOI
7 B. Flagg, L. Cox, S. McDowell, J.M. Mwose, J.M. Buelow, "Nursing Identification of Delirium," Clinical Nurse Specialist, Vol. 24, No. 5, pp. 260-266, 2010.   DOI
8 S. Dahlke, A. Phinney, "Caring for Hospitalized Older Adults at Risk for Delirium: The Silent, Unspoken Piece of Nursing Practice," Journal of Grontological Nursing, Vol. 34, No. 6, pp. 41-47, 2008.   DOI
9 J.L. Rudolph, "Delirium: An Independent Prdictor of Functional Decline after Cardiac Surgery," Journal of the American Geriatrics Society, Vol. 4, No. 58, pp. 643-649, 2010.   DOI
10 J.H. Jung, J.H. Lim, E.J. Kim, H.C. An, M.K. Kang, J. Lee, et al, "The Experience of Delirium Care and Clinical Feasibility of the CAM-ICU in A Korean ICU," Clinical Nursing Research, Vol. 22, No. 1, pp. 95-111, 2013.   DOI
11 G. Hripcsak, D.K. Vawdrey, M.R. Fred, S.B. Bostwick, "Use of Electronic Clinical Documentation: Time Spent and Team Interactions," Journal of The American Medical Informatics Association, Vol.18, No. 2, pp. 112-119, 2011.   DOI
12 S.L. Soja, P.P. Pandharipande, S.B. Fleming, B.A. Cotton, L.R. Miller, S.G Weaver, et al, "Implementation, Reliability Testing, and Compliance Monitoring of the Confusion Assessment Method for The Intensive Care Unit in Trauma Patients," Intensive Cre Medicine, Vol. 34, No. 7, pp. 1263-1271, 2008.   DOI
13 M. Hare, S. McGowan, D. Wynaden, G. Speed, I. Landsborough, "Nurses' Descriptions of Changes in Cognitive Function in The Acute Care Setting," Australian Journal of Advanced Nursing, Vol. 26, No. 1, pp. 21-26, 2008.
14 Y. Kim, H.A. Park, "Analysis of Nursing Records of Cardiac-Surgery Patients Based on The Nursing Process and Focusing on Nursing Outcomes," International Journal of Medical Informatics, Vol. 74, No. 11, pp. 952-961, 2005.   DOI
15 D. Fick, M.R. Steis, L.C. Mion, J.L. Walls, Computerized Decision Support for Delirium Superimposed on Dementia in Older Adults: A Pilot Study. Journal of gerontological nursing. 2011;37(4):39-47.   DOI
16 M.A. Musen, B. Middleton, R.A. Greenes, Clinical Decision-Support Systems, Biomedical informatics: Springer, pp. 643-674.
17 K.L. Rice, M. Bennett, M. Gomez, K.P. Theall, M. Knight, M.D. Foreman, "Nurses' Recognition of Delirium in The Hospitalized Older Adult," Clinical Nurse Specialist, Vol. 25, No. 6, pp. 299-311, 2011.   DOI
18 A. Nilsson, B.H. Rasmussen, D. Edvardsson, "Falling Beind: A Substantive Theory of Care for Older People with Cognitive Impairment in Acute Settings," Journal of Clinical Nursing, Vol. 22, No. 11-12, pp. 1682-169, 2013.   DOI
19 A. Wolf, I. Ekman, L. Dellenborg,"Everyday Practices at The Medical Ward: A 16-Month Ethnographic Field Study," BMC Health Services Research, Vol. 12, No. 1, pp. 184-196, 2012.   DOI
20 M.R. Steis, D. Fick, "Are Nurses Recognizing Delirium? A Systematic Review," Journal of Gerontological Nursing, Vol. 34, No. 9, pp. 40-49, 2008.   DOI
21 P. Voyer, M. Cole, J. McCusker, S. St-Jacques, J. Laplante, "Accuracy of nurse documentation of delirium symptoms in medical charts," International Journal of Nursing Practice, Vol. 14, No. 2, pp. 165-177, 2008.   DOI
22 S. Chow, N. Mujahid, K. Butterfield, L. McNicoll, "We can Do it: Nursing Educational Intervention to Increase Delirium Documentation," Journal of Gerontology & Geriatric Research, Vol. 3, pp. 2-7, 2015.
23 S.K. Inouye, C.H. Van Dyck, C.A. Alessi, S. Balkin, A.P. Siegal, R.I. Horwitz, "Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium," Annals of Internal Medicine, Vol. 113, No. 12, pp. 941-948, 1990.   DOI
24 J. Gordon, D. Melillo, A. Nannini, E. Lakatos, "Bedside Coaching to Improve Nurses' Recognition of Delirium," Journal of Neuroscience Nursing, Vol. 45, No. 5, pp. 288-293, 2013.   DOI
25 D.J. Ryan, N.A. O'Regan, R.O Caoimh, J. Clare, S. Gupta, "Delirium in An Adult Acute Hospital Population: Predictors, Prevalence and Detection," BMJ open, Vol. 3, No. 1, pp. 1-9, Jan 2013.
26 Y. Kang, W. Moyle, M. Cooke, S.T. O'dwyer, "An Educational Programme to Improve Acute Care Nurses' Knowledge, Attitudes and Family Caregiver Involvement in Care of People with Cognitive Impairment," Scandinavian Journal of Caring Sciences, Vol. 31, No. 3, pp. 631-640, 2016.   DOI
27 D. Fick, L.C. Mion, "Delirium Superimposed on Dementia," The American Journal of Nursing, Vol. 108, No. 1, pp. 52-60, 2008.   DOI
28 D.F. Polit, C.T. Beck, Nursing research: Generating and assessing evidence for nursing practice, Lippincott Williams & Wilkins, pp. 455-456, 2008.
29 D.P. Hartmann, "Considerations in The Choice of Interobserver Reliability Estimates," Journal of Applied Behavior Analysis, Vol. 10, No. 1, pp. 103-116, 1977.   DOI
30 S.E. Stemler, "A Comparison of Consensus, Consistency, and Measurement Approaches to Estimating Interrater Reliability," Practical Assessment, Research and Evaluation, Vol. 9, No. 4, pp. 1-9, 2004.
31 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5(R)), Washington, D.C. Aerican Psychiatric, pp. 596-598, 2013.
32 J. McCusker, M. Cole, N. Dendukuri, E. Belzile, "Does Delirium Increase Hospital Stay?," Journal of the American Geriatrics Society, Vol. 11, No. 51, pp.1539-1546, 2003.
33 Z. Zhang, L. Pan, H, Ni, "Impact of Delirium on Clinical Outcome in Critically Ill Patients: A Meta-Analysis," General hospital psychiatry, Vol. 2, No. 35, pp.105-111, 2013.   DOI
34 J. Witlox, K.J. Kalisvaart, W.A. van Gool, P. Eikelenboom, J.F.M. de Jonghe, L.S.M. Eurelings, "Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-Analysis," JAMA, Vol. 4, No. 304, pp. 443-451, 2010.
35 S.K. Inouye, R.G.J. Westendorp, J.S. Saczynski, "Delirium in Elderly People," Lancet, , Vol. 9920, No. 383, pp. 911-922, 2014.
36 O.L. Wong, "Contextual Barriers to The Successful Implementation of Family-Centered Practice in Mental Health Care: A Hong Kong Study," Archives of Psychiatric Nursing, Vol. 28, No. 3, pp. 212-219, 2014.   DOI
37 S.K. Inouye, L. Leo-Summers, Y. Zhang, S.T. Bogardus, D.L. Leslie, J.V. Agostini, "A Chart-Based Method for Identification of Delirium: Validation Compared with Interviewer Ratings Using The Confusion Assessment Method," Journal of The American Geriatrics Society, Vol. 53, No. 2, pp. 312-318, 2005.   DOI
38 M. Ehnfors, B. Smedby, "Nursing Care as Documented in Patient Records," Scandinavian Journal of Caring Sciences, Vol. 7, No. 4, pp. 209-220, 1993.   DOI
39 J.R. Landis, G.G. Koch, "The Measurement of Observer Agreement for Categorical Data," Biometrics, Vol. 33, No. 1, pp. 159-174, 1977.   DOI
40 M. Christensen, "An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective," Intensive and Critical Care Nursing, Vol. 30, No. 1, pp. 54-60, 2014.   DOI
41 Y. Kang, W. Moyle, M. Cooke, S. O'Dwyer, "Qualitative Evaluation of A Delirium Prevention and Management Programme," Journal of Clinical Nursing, Vol. 26, No. 23-24, pp. 4574-4582, 2017.   DOI