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Delirium Screen Date Commenced: / / Look for (if you answer ‘yes’ to any of the questions below please complete assessments) BOWEL PAIN BLADDER Y N Assessments to be completed Comments (including follow-up conducted) • Changes in urine colour, frequency, amount (small volumes), odour • Urine retention i.e. when was the last time the person urinated? • Has the person recently become incontinent (or increased episodes)? • Person is displaying genital area discomfort i.e. scratching • Changes in bowel habits • Is there evidence of pain/cramps or bloating? i.e. person holding tummy • Diarrhoea that may be constipation with ovelow • Appetite or oral intake decreased • Are there signs of localised infection? i.e. pain, redness, swelling, ooze • Conduct a physical assessment – are there signs of pressure sores, ingrown toenails, mouth ulcers? • Evidence of pneumonia, colds or flu i.e. increased breathing, runny rose, pale skin, productive cough, wheeze • Have there been any changes in the person’s medications? Medications are a common cause of delirium in the older person, especially sedatives, anti-psychotics, anti-depressants, diuretics, steroids or painkillers. The sudden withdrawal of medications or the introduction of new medications may cause a delirium, as can the sudden cessation of alcohol. MEDICATION REVIEW WITH GP OR COMMUNITY PHARMACIST URINALYSIS COMPLETED Date / / Blood Leucocytes pH If traces of leucocytes please collect MSU and contact GP CHECK BOWEL CHART (7 DAYS) Bristol Stool Score Last BO / / Number of days BNO If over 3 days BNO or Bristol Stool type 1 or 2 refer to Bowel Management plan and/or review current strategies. Refer to Joanna Briggs Institute Management of Constipation (2008). ABBEY PAIN SCALE COMPLETED Abbey pain scale score If Abbey score is over 2 please contact GP to review current prescribed analgesic medication and/or refer to pain management plan. If any signs of infection please consult GP. If any potential pressure areas noted review PAC plan. CLINICAL INVESTIGATION COMPLETED, APPROPRIATE CHANGES MADE BLADDER SCAN/PALPATION Date / / If any signs of distension or retention please contact GP Temp BP Resp SaO2 (if able) If any signs of infection i.e. T above 37.5, BP above normal range and increased respirations please consult GP. Signature Could your resident be experiencing delirium? Recent and sudden behavioural changes should be carefully considered for signs. People with delirium can experience heightened arousal, become restless, agitated and aggressive. Alternately, they may be withdrawn, sleepy, and quiet. This tool is designed to assist health care professionals assess, treat and/or eliminate sources of delirium that may be impacting on a person’s exacerbation of Behavioural and Psychological Symptoms of Dementia (BPSD). INFECTION MEDICINES INFECTION CHECK COMPLETED • Does the person have a history of any conditions that could cause pain e.g. angina, arthritis, fractures? • Observe the person’s physical appearance such as gums/teeth, mouth, ear, toenails for any abnormalities i.e. redness, ooze, bleeding • Has the person recently had surgery? • Assess the person’s skin integrity. Are there reddened areas or breaks in skin? A PARTNERSHIP LED BY Phone: 1800 699 799 Email: [email protected] Online: www.dementia.com.au Dementia Support Australia receives funding from the Australian Government.
