Analysis of a health team's records and nurses' perceptions concerning signs and symptoms of delirium.

This study investigates the extent of under-diagnosis of acute confusion/delirium by analyzing the records of a health team and the perception of nurses concerning this phenomenon. This quantitative study was developed in a central university hospital in Portugal and used the documentary and interview techniques. The sample obtained through the application of the NeeCham's scale was composed of 111 patients with the diagnosis of acute confusion/delirium hospitalized in the medical and surgical acute care units. A rate of 12.6% of under-diagnosis was identified in the records and a rate of 30.6% was found taking into account the perception of nurses. No indicators of acute confusion/delirium were found in 8.1% of the 111 cases and only 4.5% of the patients were diagnosed with acute confusion/delirium. The results indicate there is difficulty in identifying acute confusion/delirium, with implications for the quality of care, suggesting the need to implement training measures directed to health teams.