Delirium

Delirium Nursing Care Plans Diagnosis and Interventions

Delirium NCLEX Review Care Plans

Nursing Study Guide on Delirium

Delirium is best described as a disturbance which results to cognitive deficits, attentional deficits, disturbance in circadian rhythm, emotional disturbance, and altered psychomotor functions.

The full pathogenesis of this medical condition is unknown; however, it is believed that delirium occurs due to the disruption to the body’s equilibrium.

Delirium is commonly seen in hospitalized older adults, with an incidence rate ranging between 29 to 64%. It is associated with increased mortality, cognitive and functional decline, risk for falls, and prolonged hospital stay.

Types of Delirium

Delirium has been classified into three types: hyperactive delirium, hypoactive delirium, and mixed delirium.

  1. Hyperactive delirium – associated with agitation and hypervigilance
  2. Hypoactive delirium – characterized by drowsiness and apathy
  3. Mixed delirium – refers to the combination of both hyperactive and hypoactive delirium

Signs and Symptoms of Delirium

The signs and symptoms of delirium may not be constantly present throughout the course of the condition. The signs and symptoms are known to get worse at night and/or when the environment is less familiar to the patient. The signs and symptoms can also vary and may include the following:

  • Reduced awareness of the environment
    • Difficulty to remain focused on a subject or the tendency to switch topics
    • Being stuck on an idea with failure to respond to questions or conversations
    • Being easily distracted
    • Being withdrawn from the environment
  • Cognitive impairment
    • Short-term memory loss
    • Disorientation
    • Inability or difficulty remembering words
    • Nonsense speech
    • Difficulty understanding speech
    • Difficulty reading or writing
  • Behavioral changes
    • Hallucinations
    • Restlessness, agitation, or combative behavior
    • Making random sounds such as calling out and moaning
    • Lethargy
    • Sleep disturbance
    • Disturbance in circadian rhythm or sleep-wake cycle
  • Emotional disturbance
    • Anxiety
    • Paranoia
    • Depression
    • Euphoria
    • Apathy
    • Mood changes
    • Personality changes

Causes and Risk Factors of Delirium

Many healthcare professionals agree that delirium occurs due to the disturbance in the communication system in the brain. This disturbance can be caused by several “triggers” or factors. Delirium can be due to a single cause or a combination of several factors, such as:

  • Drug toxicity
  • Alcohol intoxication / alcohol withdrawal
  • A critical medical condition such as stroke, heart attack, lung, or liver disease, or an injury from an accident
  • Metabolic imbalances such as high or low electrolytes levels
  • Terminal illness
  • Acute infection
  • Exposure to toxins or poison
  • Malnutrition
  • Dehydration
  • Sleep deprivation
  • Pain
  • Emotional distress
  • Surgery or any procedure involving the use of anesthesia
  • Medication use – several medications are known to trigger the occurrence of delirium:
    • Pain medications
    • Sleep medications
    • Drugs to treat mood disorders
    • Allergy medications
    • Asthma medications
    • Medications for spasm and convulsions

The following are the risk factors associated with delirium:

  • Brain disorders such as dementia, stroke, and Parkinson’s disease
  • A previous episode of delirium
  • Visual or hearing impairment
  • Having multiple medical problems

Complications of Delirium

Delirium can occur rapidly and may last for a few hours to a few days or weeks. Complications of delirium commonly occur in people with a critical illness, and may include:

  1. General decline in health
  2. Poor recovery
  3. Possible need for institutional care
  4. Higher risk of death

Diagnosis of Delirium

The diagnosis of delirium does not only focus on identifying the presence of the condition, but it also aims in assessing the possible underlying cause or precipitating factors.

  • DSM-5 criteria – doctors commonly follow the DSM-5 criteria in the diagnosis of delirium. The criteria require a new acute disturbance in cognition, fluctuating attention, and altered sleep-wake cycle that are related to an underlying medical condition other than dementia.
  • The confusion assessment method (CAM) – a tool that is used in some hospitals to assess new confusion which can raise suspicion for the presence of delirium.

The other procedures below also involve the identification of the features of delirium to raise suspicion and come up with a diagnosis:

  • A thorough patient-interview
  • Physical examination
  • Cognitive testing
  • Neuro examination
  • Review of medical chart and collateral information
  • Other tests including blood and urine sample testing may be used to identify underlying medical conditions that can precipitate delirium.

Treatment of Delirium

The treatment of delirium begins by treating the underlying medical condition or other causes. After the cause has been identified and corrected, the treatment will focus on providing the brain a conducive environment for calming and healing.

  1. Supportive care – supportive care aims on the following:
    • Protecting the airway
    • Maintaining proper hydration and nutrition
    • Mobility assistance
    • Pain management
    • Addressing incontinence
    • Avoiding physical restraints and contraptions such as bladder tubes and intravenous lines unless necessary
    • Promotes family involvement in care
  2. Medications use. There is no known medication available to treat delirium yet; however, there are drugs that can be used to relax and calm a person with delirium, such as anxiolytics or anti-anxiety medications, and several antipsychotics. Benzodiazepines may be used for delirium that is caused by alcohol or drug withdrawal.
  3. Therapies. Some cases of delirium may not respond to medications. In these cases, therapy sessions involving reorientation with a family member or caregiver to prevent agitation and aggression are recommended. Motivational enhancement therapy and cognitive behavioral therapy (CBT) can also be beneficial to patients with delirium.

Nursing Care Plans for Delirium

Nursing Care Plan 1

Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to delirium as evidenced by problems with coordination and motor functions, difficulty handling complex tasks, confusion and disorientation, and inability to do activities of daily living (ADLs) as normal

Desired Outcome: The patient will be able to establish optimal mental and physical functioning.

InterventionsRationales
Assess the patient’s level of confusion.To monitor effectiveness of treatment and therapy.
Assist the patient performing activities of daily living. Consider one-to-one nursing.To maintain a good quality of life and promote dignity by allowing the patient to perform their ADLs while maintaining safety.
Simplify tasks for the patients by using simple words and instructions. Label the drawers with simple words and big letters and use written notes when necessary.Patients with delirium may have difficulty handling complex tasks.  
Provide opportunities for the patient to have meaningful social interaction, but never force any interaction.To prevent feelings of isolation. However, forced interaction can make the patient agitated or hostile due to confusion.
Allow the patient to display abnormal behavior within acceptable limits and while maintaining patient safety.To prevent agitation and increase the sense of security while allowing the patient to perform activities that are difficult to stop for him/her.    

Nursing Care Plan 2

Nursing Diagnosis: Impaired Verbal Communication related to altered perceptions secondary to delirium as evidenced by difficulty of establishing verbal communication, inability to discern usual or normal communication patterns, cognitive disturbances such as thought blocks, hallucinations/ delusions, and poverty of speech

     Desired Outcome: The patient will be able to establish reality-based thought process and effective verbal communication.

InterventionsRationales
Assess and monitor the patient’s coherence of speech and cognitive ability.To help establish baseline, as well as short-term and long-term goals.
Ensure that the patient receives the prescribed medications on time, with the right dosage and route. Have the patient take the medication in front of you.Correct administration of anti-psychotic and/or anxiolytic mediations helps the patient have clear thinking and a more functional cognitive ability.
Patients with mental health problems such as having delirium may not take medications correctly, or at all, so it is crucial for the nurse or caregiver to ensure that the patient has swallowed the oral medication completely.
Create an environment that is calm, quiet, well-lit, and conducive to effective communication.Having an environment that is free from disturbing stimuli helps in preventing confusion or hallucination in a patient with delirium.
Speak slowly, keep voice in low volume, and use clear and simple words when communicating with the patient.Loud or high-pitched voice may trigger anxiety, agitation, or confusion in a patient with delirium. Using simple words and speaking clearly can help the patient understand what is being said.
Educate the patient on ways to improve verbal communication, such as: Focusing on important activities of daily living and meaningful tasks
Replacing irrational thoughts with rational thoughts
Performing deep breathing exercises and calming techniques
Seeking support from staff, caregiver, family, or other supportive people
To gradually help the patient achieve effective cognitive thinking and functional speech.

Nursing Care Plan 3

Nursing Diagnosis: Self-Care Deficit related to cognitive impairment with secondary to delirium, as evidenced by foul body odor, disheveled appearance, and inability to perform self-care activities as normal

           Desired Outcome: The patient will be able to perform self-care activities appropriately.

InterventionRationale
Assess the patient’s limitations to self-care by asking open-ended questions. Observe the patient’s cognitive and functional ability to perform self-care activities.  To explore the patient’s self-care limitations and needs while allowing him/her to express his/her personal thoughts and feelings related to ADLs.
Allow sufficient time for the patient to perform his/her toileting routine without interrupting or rushing but offering help whenever it is needed.To promote the patent’s autonomy and independence while ensuring patient’s safety and support by the nurse or carer’s presence. Avoiding to rush the patient when doing self-care routines or rituals can help prevent mental stress to the patient.
Educate the patient’s carer or significant other on providing appropriate assistance to the patient while he/she performs self-care tasks.To provide learning to the carer or significant other and to ensure that the patient has a good amount of support while doing ADLs at home. Skilled home services might be needed if there is no available significant other to care for the patient.
Create a urinary and bowel routine care program with the patient’s carer if he/she is not able to complete toileting on his/her own. This may include toilet training by taking the patient to the bathroom every 2 to 3 hours.To help identify problems in urinary and bowel care and resolve these issues through careful planning and monitoring.
Encourage the patient to use assistive devices and grooming aids as needed.To promote autonomy when performing self-care activities.

Other possible nursing diagnoses:

  • Impaired Memory
  • Impaired Social Interaction
  • Risk for Injury
  • Risk for Self or Other-directed Violence

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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