Intervenção de enfermagem para prevenir o delirium em adultos gravemente enfermos

Contreras, Claudia Consuelo Torres; Páez-Esteban, Astrid Nathalia; Rincon-Romero, Mayerli Katherine; Carvajal, Raquel Rivera; Herrera, Marisela Márquez; Castillo, Alfredo Hinestrosa Díaz del

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Revista da Escola de Enfermagem da USP

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ORIGINAL ARTICLE • Rev. esc. enferm. USP 55 • 2021 • https://doi.org/10.1590/S1980-220X2019035003685 copiar

Intervenção de enfermagem para prevenir o delirium em adultos gravemente enfermos

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Objetivo:

Determinar a eficácia de uma intervenção de enfermagem para prevenção do delirium em pacientes críticos.

Método:

Foi realizado um estudo quasi-experimental com grupo controle não equivalente e com avaliação antes e após a intervenção. 157 pacientes faziam parte do grupo intervenção e 134 do grupo controle. Os pacientes foram acompanhados até a alta da UTI ou óbito. A incidência de delirium em ambos os grupos foi comparada. Além disso, as medidas de efeito foram ajustadas para o escore de propensão.

Resultados:

A incidência e a taxa de incidência de delirium no grupo controle foram de 20,1% e 33,1 por 1000 pessoas-dia (IC 95% 22,7 a 48,3) e no grupo de intervenção foi de 0,6% e 0,64 por 1000 pessoas-dia (IC 95% 0,22 a 11,09), respectivamente. O Hazard Ratio bruto foi de 0,06 (IC 95% 0,008 a 0,45) e ajustado de 0,07 (IC 95% 0,009 a 0,60). O número que precisava ser tratado era seis.

Conclusão:

A baixa incidência de delirium em pacientes gravemente enfermos com intervenção demonstrou a eficácia das intervenções. O tempo médio de intervenção foi de 4 dias com dedicação de 15 minutos para cada paciente.

DESCRITORES:
Delírio; Enfermagem de Cuidados Críticos; Estudos Controlados Antes e Depois

Category	Control group		Intervention group		P-value
Category	N	%	N	%
Gender
Female	49	36.6	80	51.0	0.01
Male	85	63.4	77	49.0	0.01
Years of age ≥ 60	81	60.4	100	63.7	0.6
Origin
External	23	17.2	43	27.4	0.03
Emergency Department	42	31.3	41	26.1
Surgery	18	13.4	9	5.7
Hospitalization	51	38.1	64	40.8
Diagnostic group
Medical	68	50.7	134	85.9	<0.01
Surgery	48	35.8	10	6.4
Trauma	3	2.2	8	5.1
Neurology/ neurosurgery	15	11.2	4	2.6
Urgent admission	18	13.4	11	7.0	0.07
Morphine use	30	22.4	31	19.7	0.86
Use of sedatives	34	25.4	23	14.7	0.02
Infection	62	46.3	71	45.2	0.86
Metabolic acidosis	27	20.1	38	24.2	0.41
Mechanical ventilation	58	43.3	17	10.8	<0.01
APACHE II Score >14	88	65.7	127	80.9	<0.01
Hospital stay ≥5 days	75	56.0	50	31.8	<0.01
Coma	11	8.2	2	1.3	0.03
PREDELIRIC > 50	32	26.2	49	31.2	0.4

	Hazard Ratio	Confidence interval	p-value	Relative Risk	Confidence interval	p-value
Crude	0.06	0.008 to 0.45	<0.01	0.03	0.004 to 0.23	<0.01
Adjusted ^* * Adjusted for the propensity score	0.07	0.009 to 0.60	<0.01	0.05	0.006 to 0.41	<0.01

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Author corresponding: Claudia Consuelo Torres Contreras, Faculty of Nursing, Universidad de Santander, Lagos del Cacique University Campus, Calle 70, n. 55-210, CODE 680003 - Bucaramanga, Colombia. clau.torres@mail.udes.edu.co

EXPERIMENTAL GROUP	To perform the intervention, a quiet and private environment was provided by closing the entry device in the cubicle (doors, curtains), providing privacy. The intervention was daily performed from admission to discharge from the ICU by two previously trained nurses; the intervention lasted approximately 15 minutes. The activities carried out are described below: COGNITIVE STIMULATION - Spatial and temporal orientation: Daily greetings, call the patient by their name, daily information of space, place and the reason for admission. A conversation was initiated actively listening about current and past events or news to interest and stimulate the person while guiding on time, place, person, and family. Cognitively stimulation activities: word search games, crosswords. Duration: Five minutes every day. - Visual and auditory stimulation: direct visual contact, frequent use of contact, the use of vision and hearing devices (glasses, hearing aids), active listening to the patient being allowed to express their concerns and answer questions were promoted. During contact with the patient, they spoke slowly, medium tone of voice, use of short and clear phrases. Concrete and specific communication was maintained. Photographs, letters and magazine drawings or made by family members were shown. Nurses asked for the list of personal items that the patient would like to have during their hospital stay to obtain them such as glasses, hearing aids, dentures, family photos, religious objects, etc. Use of relationship games, for example, indicate in a list the objects that go in the fridge. Duration: Five minutes every day. FAMILY SUPPORT The involvement of family and caregivers in self-care and patient reorientation was encouraged. Education about delirium and its complications. The accompaniment and approach of the patient to a relative or person of his confidence were facilitated, as long as possible. Duration: Five minutes every day during visiting time.	Daily monitoring of the application of CAM ICU -RASS: Every day the intervention was performed and the CAM ICU scale was applied to verify the effect of the intervention (delirium development or not). If the patient worsened his state of health or his level of sedation and did not allow the intervention, the subject continued to follow up to the improvement of the conditions to continue delirium prevention activities. A maximum time of 8 days was established to stop patient intervention if their medical condition did not improve or there were changes in the Rass scale to allow the application of the CAM-ICU scale. The research team did not change or titrate sedation levels of the study patients.
CONTROL GROUP	The usual care consisted of standard hospital care (Orientation, reduction of environmental stimuli: noise, lighting) provided by general physicians, medical specialists, nurses and support staff. The members of the intervention team did not provide services in patients assigned to usual care (Control Group). However, the same group of physicians and medical specialists, nurses and support staff and resident doctors will provide usual care in both study groups.	Daily monitoring of the application of CAM ICU -RASS: Every day the intervention was performed and the CAM ICU scale was applied to verify the effect of the intervention (delirium development or not). If the patient worsened his state of health or his level of sedation and did not allow the intervention, the subject continued to follow up to the improvement of the conditions to continue delirium prevention activities. A maximum time of 8 days was established to stop patient intervention if their medical condition did not improve or there were changes in the Rass scale to allow the application of the CAM-ICU scale