Emergence Delirium: A Nursing Perspective - AORN

MARCH 2009, VOL 89, NO 3HudekDocumenting the presence ofemergence delirium is important,and nursing care provided to manageit should be included in thepatient’s plan of care.by the medication or the fact that children premedicatedwith midazolam had a slower awakeningfrom anesthesia. 3 In another study, researchersfound that premedication with midazolamdid reduce the incidence of negativebehaviors postoperatively but did not necessarilyreduce the incidence of emergence delirium. 6Wells et al concluded from their observationsthat premedication with an anti-anxiety medicationdoes not prevent emergence delirium. 5 Allthese authors agree that there is a complex networkof factors that intermingle in trying to decipherthe cause of emergence delirium; therefore,trying to prevent emergence delirium isjust as multifaceted. 3,5,6It is important to provide a calm and reassuringenvironment with constant reality orientationfor patients experiencing emergencedelirium. Patients displaying paranoid ideationwill need continual guidance. 3-5 Patients whoslip into unconsciousness need to be reorientedeach time they regain consciousness. Controllingthe environment and providing adequateand proper stimulation for the patient isimportant. This may include having familymembers remain with the patient throughouthis or her PACU stay. 4Adequate and proper stimulation for the patientis individualized based on the patient’smaturational level and coping mechanisms. Fora child, having the parents present and playingsoothing music may be appropriate. 3 If the parentsare highly anxious or distraught at seeingtheir child in an agitated state, however, thechild may respond better without the parentspresent. In one incident of emergence delirium,an adult patient was convinced that his wifewas in grave danger. The nurse brought his wifeinto the PACU to assure him that she was allright. His wife stayed in the unit to reassure himthroughout his recovery. 1 Other patients may becomforted by a quiet environment with littledisturbance and calm, quiet care from staffmembers.DOCUMENTATION AND PATIENT TEACHING. Documentingthe presence of emergence delirium is important,and nursing care provided to manageit should be included in the patient’s plan ofcare (Table 1). The presence of emergence deliriumand how to care for the patient after dischargeshould be explained to family membersand caregivers. Family members or caregiversalso should be made aware that in older adultpatients, the presence of emergence deliriummay be a harbinger of postoperative delirium,which can appear hours, days, or weeks aftersurgery. 4 Emergence delirium also may be associatedwith maladaptive behavior in childrenmonths after surgery. 6 This behavior may be expressedas generalized anxiety, nighttime crying,enuresis, temper tantrums, and separationanxiety. Postoperative teaching is important tohelp caregivers be alert for the onset of postoperativedelirium and maladaptive behaviorsand provide support to the patient.DECREASING THE RISK OF EMERGENCE DELIRIUMThere is no identified way of preventingemergence delirium, but there are steps nursescan take that may decrease its incidence. Identifyingrisk factors for emergence delirium canaid in identifying patients who might experienceit and allow staff members and the patient’sfamily members or caregivers to manageit if it occurs. 2,4 Risk factors include• the patient’s age,• type of surgery,• type of anesthesia,• previous response to surgery,• pre-existing medical conditions, and• current medications.PREOPERATIVE ASSESSMENT. Administering a structuredpreoperative evaluation of the risk factorsfor emergence delirium, as well as the patient’sanxiety, can alert perioperative team members to512 • AORN JOURNAL