Nursing microtheory in the prevention of <i>delirium</i> in older adult in the intensive care unit

Kinalski, Sandra da Silva; Beuter, Margrid; Benetti, Eliane Raquel Rieth; Leite, Marinês Tambara; Venturini, Larissa; Brandão, Marcos Antônio Gomes

doi:10.1590/1518-8345.6707.4071

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Revista Latino-Americana de Enfermagem

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Original Article • Rev. Latino-Am. Enfermagem 31 • 2023 • https://doi.org/10.1590/1518-8345.6707.4071 copy

Nursing microtheory in the prevention of delirium in older adult in the intensive care unit^* * Paper extracted from doctoral dissertation “Microtheory for nursing care in the prevention of delirium in elderly people in the ICU”, presented to Universidade Federal de Santa Maria, Santa Maria, RS, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to describe a microtheory for nursing care in the prevention of delirium in older adult in the intensive care unit.

Method:

prescriptive theoretical research, based on substruction. Roy’s Adaptation Model constructs were deduced and data from the phenomenon of nursing care in the prevention of delirium in older adult in intensive care were induced, based on an integrative literature review.

Results:

the microtheory has a theoretical and operational system and a model of care. In the theoretical system, Roy’s focal and contextual stimulus constructs were used. From them, the concepts of focal and contextual care and the variable adaptive response to prevention were elaborated. From the relational statements, four axioms, two postulates, eight propositions and an epistemic assumption were elaborated.

Two empirical indicators were established in the operating system:

the Confusion Assessment Method for Intensive Care Units and the demographic/clinical history of the older adult. Subsequently, two transformational statements, four hypotheses and the model of care represented in figure were produced.

Conclusion:

the microtheory produced prescribes care in the prevention of delirium in older adult in intensive care, through a construct of interest to nursing, and allows interceptions for the development of instruments that guide nursing activities.

Descriptors:
Nursing; Aged; Delirium; Nursing Theory; Intensive Care Units; Nursing Care

Highlights:

(1) It prescribes care “for” and “in” the prevention of delirium in older adult in the ICU.

(2) Microtheory developed by theoretical substruction for use in clinical practice.

(3) Tool with a philosophical perspective that guides nursing care.

(4) Empirical indicators are important to evaluate the effectiveness of interventions.

Focal Care	Interventions
Carrying out guidance activities	Promote time, place and character orientation activities (>3x/day). Carry out activities with calendars, clocks, cell phones and radios. Dialogue with older adult about past experiences and current activities.
Sensory Interventions for Visual and Hearing Impairment	Promote visual and auditory stimulation through the use of visual and hearing aids. Take an approach that facilitates visual and auditory contact. Promote assertive verbal communication, providing material adapted for visual impairments. Protect the cornea during sedation, preventing dehydration.
Sleep pattern maintenance	Provide indirect lighting, especially at night. Provide an eye mask and/or ear plugs. Adjust the medication regimen, avoiding dosing between 00:00 and 05:00 hours. Provide music therapy sessions. Reduce environmental noise. Perform pain control. Do not perform elective procedures at night. Teach and encourage deep breathing and relaxation exercises before bed. Offer massage on the feet and thoracic and lumbar regions.
Early mobilization	Promote patient mobilization in or out of bed, within 24 to 48 hours after admission to the ICU. Plan mobility schedule with range of motion exercises, active, passive and walking when possible, three times a day.
Therapeutic communication	Maintain clear and open communication with the older adult and encourage their emotional expression. Use face-to-face communication with eye contact. Use the patient’s name during communication and introduce yourself to the patient when first contact occurs. Allow them to express their thoughts and feelings. Use a communication card, WordPad or pen and paper for those undergoing endotracheal intubation or tracheostomy.
Music therapy	Provide moments of music therapy through MP3 players, as well as headphones. This action can be collective or individual.
Hydration and nutrition	Evaluate the nutritional status of the elderly on admission to the ICU, using scales such as: Geriatric Nutritional Risk Index (GNRI), Prognostic Nutrition Index (PNI), Controlling method Nutritional Status (CONUT). Ensure adequate nutrition and hydration.
Cognitive stimulation	Care aimed at stimulating cognitive function, for this, materials adapted to the needs of the older adult should be used, such as large keyboards, clocks with larger displays and books with large letters. Daily activities are recommended, at least three times a day, to stimulate memory, such as discussing current events in family life and remembering past events. To carry out the activities, the use of books, magazines and the presence of family members in the ICU is associated. Also, they can be used as stimulating activities, playing cards, word search games, crossword puzzles (daily duration of five minutes). For patients undergoing endotracheal intubation or tracheostomy, a communication card, pen, paper or WordPad can be used to establish communication and help with activities.
Night nursing care	Schedule so that most care is performed during the day. Group the care that is performed at night for specific times, avoiding repeated sleep interruptions.
Mechanical containment and indwelling catheters	Reduce the use of mechanical restraint and permanent catheters whenever possible, in order to avoid the physical restriction of the older adult in bed.
Family training on delirium	Train the patient’s family about delirium and its complications: definition, symptoms, etiology, negative effects, prevention of delirium. Education strategies such as video, folders, pamphlets, checklist.
Family participation in care	Stimulate the active participation of family members and patient companions, as emotional and affective support. Also, train them to participate in cognitive stimulation, guidance, hygiene and comfort activities for the elderly, under the supervision of the ICU nursing team.

Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br

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[1] Corresponding author:
Sandra da Silva Kinalski E-mail: sandrakinalski@yahoo.com.br https://orcid.org/0000-0002-4841-2288

Contextual Care	Interventions
Provide materials such as: clocks, calendars, cell phones, books, magazines, radios, televisions, whiteboards, pens, papers and personal belongings of the patient	Provide and make available materials that can be used in temporal and spatial orientation, cognitive stimulation and communication with the older adult. Also, encourage their involvement in the proposed activities.
Reduce artificial lighting at night	Provide indirect lighting at night to maintain sleep patterns.
Reduce the environmental noise in the ICU	Monitor and maintain adequate noise volume levels in the ICU.
Promote privacy	Maintain, whenever possible, individual beds, using curtains or screens, with a view to the well-being of the patient and the performance of care.
Adjust monitor and machine alarms	Set monitors and machines to night mode, which lowers volume and dims displays, reducing noise and promoting sleep.
Provide natural light in the environment	Provide physical structure that allows natural light to the patient, promoting day/night orientation.
Control the ambient temperature	Maintain a pleasant ICU room temperature.
Flexibility in visiting hours in the ICU	Allow and encourage the visit of family members or companions who have an emotional relationship with the older adult.