Julia Ericson RN

Chris Waszynski, APRN

Julia Ericson RN and Chris Waszynski APRN

Improving Nursing Care for the Hospitalized Cognitively Impaired Patient

Patients with cognitive impairment present a special challenge for the nursing staff.  Maintaining a safe environment while promoting function requires dedication and creativity.  Christine Waszynski APRN, Geriatric Nurse Practitioner and Coordinator of the Inpatient Geriatric Consult Service and Geriatric Resource Nurse program has led the challenge at Hartford Hospital, a NICHE site.

Persons with dementia are hospitalized three times more often and stay in the hospital significantly longer than their cognitively intact cohort.  Delirium can occur in 15-60% of the geriatric hospitalized population. Cognitively impaired patients are at high risk for falls, dehydration, inadequate nutrition, immobility, restraints, untreated pain and medication related issues during a hospital stay.

One of the first challenges is identifying the demented and/or delirious patient.  The majority of patients with these conditions are often undiagnosed by hospital staff.  At Hartford Hospital, we trialed the Confusion Assessment Method (CAM), a tool to assess for and monitor delirium on two nursing units.  The staff found it to be very helpful in identifying delirious patients and monitoring their mental status over time.  We are in the process of implementing the CAM hospital wide.

Once identified, cognitively impaired patients must be kept safe and occupied.  Hartford Hospital received grant funding to assist with this intervention.  We have purchased and educated staff on voice activated chair alarms, Freedom splints, skin sleeves, and a variety of therapeutic activities.  These activities are guided by the staff, family or trained volunteers and are targeted toward the patient's ability and interest.  This has helped to foster cognitive stimulation and prevent functional loss.  Geriatric Resource Nurses (GRNS) throughout the hospital facilitate the identification of high risk geriatric patients who may need extra attention or assessment from the Geriatric Consult Service.

Julia Ericson BSN, RN, ACRN and Russ Houghton BSN, RN, GRNS are clinical nurse leaders on Center 12, Medicine.  As the Infectious Disease unit at Hartford Hospital, the patient population on Center 12 includes a geriatric component, people who have AIDS and those struggling with substance abuse. The CAM research study confirmed that Center 12 sees a significant number of cognitively impaired patients who are younger than the norm.  Nursing care in this setting requires creative interventions to assure best patient outcomes.

In collaboration with unit staff and the multidisciplinary health care team, Julia and Russ explored alternative resources to meet the unique needs of our patients.  The process in dynamic and ongoing.  Some initiatives include:

  • Training for RN and Patient Care Assistant (PCA) staff in behavioral management and crisis intervention at the Institute of Living.
  • Use of alternatives for restraints.
  • Development of an algorithm to differentiate root causes of behavior and direct care.
  • Grant application for purchase of alternative safety equipment and therapeutic activities for patients.
  • An invitation for nursing students to volunteer as a friendly visitor; providing companionship, attention and therapeutic distraction.
  • Development of specific nursing interventions for the agitated patient.
On Center 12, we are inspired by the challenge that patients with dementia and/or delirium present.  It is exciting to take part in developing innovative approaches to their care!