Clinical SOAP Note on Delirium
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review. For this week select a patient with Delirium
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Resource to use
Course Description
This course prepares students to assess, diagnose, and manage mental health care needs across the lifespan. Emphasis will be placed on underlying acute and chronic psychiatric/mental health diagnoses. Clinical opportunities will be utilized for all PMHNP to apply concepts in primary and acute care settings with adults and families.
Program: Graduate Nursing
Resources
Carlat, D. J. (2023). The psychiatric interview (4th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971
American Nurses Association & American Psychiatric Nurse Association. (2015). Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.) (DSM-5). Washington DC: APA Press. ISBN: 978-0890425763
Johnson, K., & Vanderhoef, D. (2016). Psychiatric mental health nurse practitioner review manual (4th ed.). Silver Spring, MD: American Nurses Association. ISBN: 978-1-935213-79-6
Robert Joseph Boland, Verduin, M. L., Ruiz, P., Arya Shah, & Sadock, B. J. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Philadelphia, PA: Lippincott Williams, and Wilkins. 9781975145569
Recommended
Bickley, L. (2016). Bates’ Guide to Physical Examination and History-Taking [VitalSouce bookshelf version]. https://batesvisualguide.com/. Eleventh, North American Edition; Lippincott Williams & Wilkins: ISBN 1609137620
Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Boston, MA:Cengage. ISBN: 9781305263727
Heldt, J. P., MD. (2017). Memorable psychopharmacology. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1
Shea, S. C. (2017). Psychiatric interviewing: The art of understanding (3rd ed.) Elsevier.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press. ISBN 978-1-107-68646-5
Stahl, S. M. (2020). Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press. ISBN 978-1108926010
An acute onset syndrome, not a disease. Hallmark symptom: disturbance of CONSCIOUSNESS accompanied by changes in COGNITION. Delirium likely caused by direct physiologic process, substance use/abuse, or general medical condition) Common findings: -Develops over hours to days -Fluctuates during the day – Reversal of sleep-wake cycle (awake at night, asleep in day) – Impaired recent and intermediate memory – Psychomotor agitation (purposeless, randome actions) Common, and often overlooked. Mistaken for dementia in older persons, and for worsening psychotic symptoms in those with SMI. Symptoms can persist for months if not recognized; most resolve in 3-6 months if treated.
Delirium subtypes
Hyperactive: agitated, restless, hyperalert Hypoactive: lethargic, slowed, apathetic Mixed: cycles between hyperactive and hypoactive
Delirium incidence, demographic, prognosis
0.4% general population 1-2% those >65 14-56% of hospitalized pts poor prognosis: 50% mortality rate by 1 year Early recognition, intervention, treatment is goal: when pts clinical presentation changes rapidly from baseline, always keep delirium in differential.
Confusion Assessment Instrument (CAM)
The Confusion Assessment Method (CAM) includes two parts. Part one is an assessment instrument that screens for overall cognitive impairment. Part two includes only those four features that were found to have the greatest ability to distinguish delirium or reversible confusion from other types of cognitive impairment. http://consultgerirn.org
Delirium- Non Specific Neuro Abnormalities
Urinary Incontinence Mycoclonus Nystagnus Asterixis – flapping motion of the wrists Increased muscle tone and reflex Tremors Incoordination
Delirium- Perceptual Disturbance
Illusions most common Hallucinations – usually visual & accompanied by illusions Delusions are common
Delirium – MSE findings
GENERAL appearance: inattentive, disheveled, unconcerned SPEECH: impaired, disorganized, rambling, incoherent, slurred AFFECT: rapid, unpredictable shifts in affective state without known precipitant (lethargic to agitated) MOOD: difficult to elicit THOUGHT PROCESS: disorganized, distractible, perceptual disturbances THOUGHT CONTENT: disorganized, distorted, delusional ORIENTATION: disorientation to time & place (USUALLY FIRST SX TO APPEAR) Impaired memory, concentration, abstraction, and jdgment
Delirium: diagnostic studies
Chemistry CBC TFT Syphilis HIV UA CXR serum or urine drug screen EEG would show generalized slowing, unless ETOH withdrawal related (then would show generalized increased activity)
Delirium Non-pharm treatment
Monitor for safety, nutrition, hydration Avoid sensory-deprivation or overstimulation Frequent reality orientation (and familiar people, pictures, clock or calendar etc)
Delirium- pharmacologic treatment
Symptomatic treatment. Avoid the use of medications which can cloud clinical picture if you can (RTC’s lack consensus) Haldol – Small doses .5- 1 mg oral or IV has the most support. IV may cause Torsades, widened QT interval, deaths reported. Also acute dystonias. Atypical Antipsychotic – Risperdone .5-1.75 po according to Expert Guidelines – Quetiapine, Olanzapine (Zydis) at low dose Anxiolytics for insomnia *especially avoid Benzo’s and Anti-cholinergics which will worsen (source, Mary’s notes)
NEECHAM Confusion Scale
Processing Behavior Physiologic Control
Delirium-Causes
D-Drugs E-Electrolyte Abnormality L -Low Oxygen Saturation I -Infection R – Reduced Sensory Input I – Intercranial U – Urinary or Renal M – Myocardial What about Tumor and Poisons, thyroid, B-12 deficiency, B-12 (listed in Mary’s notes)
Delirium in Children
Especially susceptible. Can be mistaken for uncooperative behavior – suspect if child is not soothed by common methods (e.g. parent) Most common in febrile states, or with meds esp anticholinergics.
Sample/template
SOAP Note: Post-Traumatic Stress Disorder (PTSD)
Subjective:
Chief complaint (in patient’s own words): “I can’t sleep at night. I keep having these terrible nightmares about the car accident, and I’m always on edge.”
History of present illness: The patient is a 35-year-old male who presents with symptoms of PTSD following a severe car accident 6 months ago. He has stated that he suffers from intrusive thoughts, flashbacks, and nightmares about the accident. The patient says she feels always nervous and always on the alert, especially when driving or being a passenger in a car. He does not drive anymore and has missed several days at work because of his symptoms. The patient states that they have problems falling asleep and maintaining it, and they get only 3-4 hours of sleep per night. He also refers to desensitization and social isolation from his family and friends. (American Psychiatric Association, 2013).
Current Medications:
· 50 mg of sertraline every day (begun three months ago)
· 1 mg of prazosin taken before bed (begun 1 month ago)
Allergies: No known drug allergies
Past Medical History:
– Mild traumatic brain injury from the car accident (resolved)
– Hypertension (controlled with diet and exercise)
Past Psychiatric History: No history of mental illness diagnosis or treatment
Family History: father who has a history of alcoholism
Relevant personal and social history: The patient has two children, ages eight and ten, and is married. He works as an accountant but has been struggling to maintain his performance due to concentration difficulties and missed workdays. He reports increased tension in his marriage due to emotional withdrawal and irritability. The patient denies any history of substance abuse but mentions having 2-3 alcoholic drinks per night to “help fall asleep.” This level of alcohol consumption may interfere with PTSD treatment and exacerbate symptoms (Lancaster et al., 2016).
Objective:
Vitals: BP 138/88, HR 82, RR 18, Temp 98.4°F
ROS: Positive for sleep disturbance, anxiety, and concentration difficulties as described above. Otherwise, negative.
Mental Status Exam:
– Appearance: Well-groomed, appropriate attire
– Behavior: Tense, hypervigilant
– Speech: Normal rate and volume
– Mood: “Anxious and on edge”
– Affect: Constricted, anxious
– Thought Process: Linear and goal-directed
– Thought Content: Preoccupation with accident, no current suicidal or homicidal ideation
– Perceptions: No hallucinations
– Cognition: Alert and oriented x4, intact attention and concentration
– Insight: Good
– Judgment: Fair
Psychiatric Screening Measures:
– PCL-5 (PTSD Checklist for DSM-5): Score 58 (indicating severe PTSD symptoms)
– PHQ-9 (Patient Health Questionnaire-9): Score 14 (indicating moderate depression)
– GAD-7 (Generalized Anxiety Disorder-7): Score 16 (indicating severe anxiety)
These screening measures support the clinical presentation and aid in diagnosis and treatment planning (Watkins et al., 2018).
Assessment:
Primary Diagnosis: Post-Traumatic Stress Disorder (F43.10)
DSM-5 Criteria Met:
A. Exposure to actual death or threatened death in a motor vehicle accident
B. Presence of intrusion symptoms (recurrent distressing memories, nightmares, flashbacks)
C. Persistent avoidance of stimuli associated with the trauma (avoiding driving, thoughts about the accident)
D. Negative alterations in cognitions and mood (feeling detached from others, persistent negative emotional state)
E. Marked alterations in arousal and reactivity (hypervigilance, sleep disturbance, irritability)
F. Duration of disturbance is more than 1 month
G. The disturbance causes clinically significant distress and impairment in social and occupational functioning
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition
(American Psychiatric Association, 2013)
Differential Diagnoses:
1. Adjustment Disorder with Mixed Anxiety and Depressed Mood
2. Major Depressive Disorder
3. Generalized Anxiety Disorder
Potential Obstacles to Treatment:
– Avoidance behaviors reinforcing symptoms
– Alcohol use potentially interfering with treatment effectiveness
– Work-related stress and potential job insecurity
– Marital strain due to PTSD symptoms
Plan:
1. Medication Management:
· Increase Sertraline to 100 mg daily for 4 weeks, then reassess. This adjustment is based on evidence supporting the efficacy of SSRIs in PTSD treatment (Friedman, 2019).
· Continue Prazosin 1 mg at bedtime for nightmares
· Discuss risks of alcohol use with current medications and recommend gradual reduction
2. Psychotherapy:
· Refer for Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) therapy, weekly sessions for 12 weeks. These evidence-based treatments have shown significant efficacy in reducing PTSD symptoms (Watkins et al., 2018).
· Provide psychoeducation on PTSD and its treatment
3. Behavioral Interventions:
· Teach and practice grounding techniques for managing flashbacks and anxiety
· Encourage gradual exposure to driving-related stimuli using a hierarchical approach
· Implement sleep hygiene measures and stimulus control therapy for insomnia
4. Supportive Measures:
· Refer to a PTSD support group
· Recommend family therapy to address marital strain and improve family support
· Provide resources for workplace accommodations if needed
5. Substance Use:
· Educate on risks of alcohol use for PTSD symptoms and sleep
· Recommend gradual reduction of alcohol intake
· Consider referral to substance abuse counselor if unable to reduce independently
· (Lancaster et al., 2016)
6. Follow-up and Monitoring:
· Schedule follow-up appointment in 2 weeks to assess medication response and side effects
· Obtain baseline liver function tests and lipid panel
· Reassess PCL-5, PHQ-9, and GAD-7 scores at each visit to track symptom improvement
· Coordinate care with therapist and other providers
7. Safety Planning:
· Develop a crisis plan, including coping strategies and emergency contacts
· Assess for suicidal ideation at each visit
· Provide crisis hotline information
8. Patient Education:
· Provide written materials on PTSD, treatment options, and coping strategies
· Discuss importance of medication adherence and potential side effects
· Encourage lifestyle modifications: regular exercise, stress reduction techniques, and healthy sleep habits
This comprehensive treatment plan addresses the multifaceted nature of PTSD and incorporates evidence-based interventions across pharmacological, psychological, and behavioral domains (Friedman, 2019; Watkins et al., 2018).
Prognosis: With adherence to the treatment plan, including medication management and evidence-based psychotherapy, the prognosis for symptom reduction and improved functioning is generally good. However, the patient’s alcohol use and avoidance behaviors may complicate treatment. Further and changes in the strategy of the treatment will be essential for the best outcomes.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Friedman, M. J. (2019). PTSD: Pharmacotherapeutic approaches. Current Psychiatry Reports, 21(12), 1-9.
Lancaster, C. L., Teeters, J. B., Gros, D. F., & Back, S. E. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and treatment. Journal of Clinical Medicine, 5(11), 105.
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258.
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