Delirium is an acute disturbance of mental status and cognition with an acute onset of hours or days. It is often related to dehydration, infection, medications, alcohol withdrawal, dementia, organ failure, severe pain, or the dying process.
Symptoms may include:
- Reduced awareness of surroundings
- Poor memory
- Disorientation to time or place
- Nonsensical speech
- Restlessness
- Uncooperativeness
- Combativeness
- Withdrawal
- Slow movement
- Altered sleep patterns
There are three types of delirium:
- Hyperactive. Patients are often restless, anxious, have rapid mood swings, or may perceive things that aren’t there. This is the easiest type to recognize but often results in incomplete care and safety concerns due to aggressive or combative behavior.
- Hypoactive. Patients with this type of delirium are sluggish, drowsy, slow, or inactive. They may seem like they are in a daze and communicate less.
- Mixed. The patient may shift between hyperactive and hypoactive.
Older adults with a history of dementia who are admitted to the hospital are at a higher risk of experiencing delirium. Unfamiliar surroundings, medications, surgery, or infection can further exacerbate this.
Delirium is diagnosed through a mental status assessment. A physical or neurological assessment can rule out a possible stroke or other cause that may mimic delirium.
Nursing Process
Nurses play a crucial role in identifying patients experiencing delirium. Because they are the ones that provide round-the-clock bedside care, nurses should be among the first to notice any changes in cognitive behavior in the inpatient setting.
The first step to treatment is to identify the underlying cause. This will prevent further mental status deterioration and reduce safety risks. Nurses can educate family members on identifying signs of delirium.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for delirium, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for delirium.
Acute Confusion
Delirium results in acute disorientation and disruptions in cognition.
Nursing Diagnosis: Acute Confusion
Related to:
- Alcohol withdrawal
- Medication side effects
- Anesthesia
- Sleep deprivation
- Older age
- Metabolic imbalances
- Dementia
- Hypoxemia
- Severe pain
As evidenced by:
- Hallucinations
- Fluctuations in cognition
- Agitation
- Restlessness
- Inability to make decisions
- Inability to follow instructions
Expected outcomes:
- Patient will demonstrate appropriate orientation to person and place.
- Patient will cooperate with care and assessments.
- Patient will communicate needs and follow commands.
Assessment:
1. Assess electrolytes and other laboratory test results.
Abnormalities such as metabolic alkalosis, hyponatremia, hypoglycemia, or any signs of infection can signal an underlying cause of delirium.
2. Assess the patient’s consciousness and orientation.
The nurse can easily and quickly assess this by observing and asking the patient for their name, location, and date.
3. Interview the patient’s family regarding baseline behavior.
Inquiring how the patient typically behaves and speaks can help assess when the delirium started and what is abnormal or out of character.
Interventions:
1. Reorient the patient as needed.
Help to maintain reality and prevent anxiety by orienting to place and time as needed.
2. Provide familiar objects.
Pictures of family members or a favorite blanket may assist in keeping the patient calm and aware.
3. Remain calm and comforting.
Use a calm, reassuring voice and provide touch as long as it doesn’t agitate the patient. Avoid arguing with the patient who is confused.
4. Treat the underlying cause.
An infection may require antibiotics. Severe pain can be treated with opioids. Alcohol withdrawal is treated with anti anxiety medications. Dehydration requires fluid resuscitation and supplemental electrolytes.
Impaired Social Interaction
Impaired social interaction can happen in patients experiencing delirium due to altered thinking and inappropriate behavior.
Nursing Diagnosis: Impaired Social Interaction
Related to:
- Impaired cognitive functioning
- Altered thought processes
- Biochemical imbalances
As evidenced by:
- Consistent state of disorientation to environment
- Extreme confusion
- Slow/inappropriate response to questions
- Dysfunctional interaction with others
- Inability to focus
- Agitated behavior
- Drowsiness
Expected outcomes:
- Patient will respond appropriately to questions.
- Patient will participate in a group setting within their capabilities.
Assessment:
1. Assess for a support system.
Assess for the presence of family, a spouse, or friends that can assist with communication efforts.
2. Observe how the patient interacts with other people.
The patient may have increased manic behaviors when in a highly-stimulating environment. They may become loud, obscene, or threatening. Identifying environments that make the patient uncomfortable can prevent agitation.
Interventions:
1. Ensure that medications are taken as prescribed.
Some patients may not take medications correctly, either overdosing or underdosing.
2. Provide a calm environment.
Allow the patient to interact with familiar faces by providing an isolated, quiet, and nonstimulating environment.
3. Maintain routines and staff assignments.
Maintaining similar routines, such as eating and bathing schedules, can enhance orientation. If possible, keep the same staff members with the patient to promote communication and trust.
4. Differentiate between delirium and dementia.
Delirium and dementia can occur together or separately, as dementia makes the brain more susceptible to delirium. This can cause delirium to go unrecognized, even for healthcare providers. Delirium is temporary, while dementia is chronic.
Risk for Injury
Since delirium causes disorientation, confusion, and poor decision-making, it poses a significant risk for injury. Ensuring that the patient is safe during the course of recovery is a priority.
Nursing Diagnosis: Risk for Injury
Related to:
- Changes in cognitive function
- Disorientation, confusion
- Unfamiliar environment
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient’s family will implement strategies to reduce the risk of injury.
- Patient will remain free of injury.
Assessment:
1. Assess mental status and cognitive awareness.
Changes in mental and cognitive awareness may increase the risk for injury.
2. Assess for sensory-perceptual impairment.
Confused or disoriented patients may have difficulty perceiving environmental stimuli that place them at risk for injuries or falls.
3. Check the patient’s environment for threats to safety.
Patients experiencing cognitive deficits are at risk for common hazards. Clutter, toxic cleaning products, stairs, and easily accessible medications can be hazards.
Interventions:
1. Remain with the patient when agitated or combative.
Staff may need to remain at a distance to prevent injury to themselves, but remaining at the bedside may be necessary to prevent the patient from injuring themselves. Restraints are considered as a last resort.
2. Familiarize them with their environment.
Hospitalization, especially for long durations or associated with surgery or ICU admission, increases the incidence of delirium. Familiarize the patient with their environment and advise on how to call for assistance.
3. Keep items in close reach.
Eyeglasses and hearing aids should be kept close as poor vision and hearing can worsen confusion.
4. Administer antipsychotics.
Patients who are severely combative or uncooperative may require IV or IM medications to induce sedation. Haloperidol is a common medication given to agitated patients to reduce the risk of harm to themselves and others.
References
- Doenges, M. E., Moorhouse, M. F. (1993). Nurse’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
- Delirium. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386. Accessed Dec. 4, 2022
- Bennett, C. (2019). Caring for patients with delirium. Wolters Kluwer Health., Inc.
