Delirium is an acute disturbance in mental function characterized by reduced awareness of the environment and altered attention. This nursing diagnosis focuses on identifying, managing, and preventing delirium while providing comprehensive care for affected patients.
Causes (Related to)
Delirium can develop due to various factors, with several conditions contributing to its onset and progression:
- Medical conditions such as:
- Medication-related factors including:
- Polypharmacy
- Anticholinergic medications
- Sedatives and narcotics
- Sudden medication withdrawal
- Environmental factors such as:
- Unfamiliar surroundings
- Sensory deprivation or overload
- Sleep disruption
- Physical restraints
Signs and Symptoms (As evidenced by)
Delirium presents with characteristic signs and symptoms that nurses must recognize for accurate diagnosis and intervention.
Subjective: (Patient reports)
- Confusion about time and place
- Visual or auditory hallucinations
- Disturbed sleep-wake cycle
- Difficulty concentrating
- Memory problems
- Emotional lability
Objective: (Nurse assesses)
- Fluctuating mental status
- Disorganized thinking
- Altered level of consciousness
- Reduced awareness of the environment
- Disorientation
- Agitation or lethargy
- Impaired attention span
- Changes in psychomotor behavior
Expected Outcomes
The following outcomes indicate successful management of delirium:
- The patient will demonstrate improved orientation to person, place, and time
- The patient will maintain safety
- The patient will show improved cognitive function
- The patient will maintain a normal sleep-wake cycle
- The patient will demonstrate reduced agitation
- Family/caregivers will understand delirium management strategies
- The patient will return to baseline mental status
Nursing Assessment
Monitor Mental Status
- Assess the level of consciousness
- Evaluate orientation
- Check attention span
- Monitor cognitive changes
- Document behavioral changes
Assess Physical Status
- Monitor vital signs
- Check oxygen saturation
- Assess pain levels
- Review medication effects
- Monitor intake and output
Evaluate Environmental Factors
- Assess sleep patterns
- Check for environmental triggers
- Monitor noise levels
- Evaluate lighting conditions
- Document safety measures
Screen for Contributing Factors
- Review medical history
- Check current medications
- Assess for infections
- Monitor laboratory values
- Evaluate organ function
Assess Support Systems
- Document family involvement
- Evaluate caregiver understanding
- Check available resources
- Monitor support needs
- Assess coping mechanisms
Nursing Care Plans
Nursing Care Plan 1: Acute Confusion
Nursing Diagnosis Statement:
Acute Confusion related to multiple etiological factors (metabolic imbalance, infection, medications) as evidenced by fluctuating level of consciousness, disorientation, and impaired attention span.
Related Factors:
- Metabolic disturbances
- Acute infection
- Medication side effects
- Sleep deprivation
- Unfamiliar environment
Nursing Interventions and Rationales:
- Perform frequent orientation assessment
Rationale: Monitors mental status changes and effectiveness of interventions - Maintain consistent caregivers
Rationale: Promotes familiarity and reduces confusion - Implement reality orientation techniques
Rationale: Helps maintain cognitive function and orientation
Desired Outcomes:
- The patient will demonstrate improved orientation
- The patient will show an increased attention span
Nursing Care Plan 2: Risk for Injury
Nursing Diagnosis Statement:
Risk for Injury related to altered mental status and impaired judgment as evidenced by confusion and agitation.
Related Factors:
- Cognitive impairment
- Altered perception
- Poor judgment
- Psychomotor agitation
- Environmental hazards
Nursing Interventions and Rationales:
- Implement safety precautions
Rationale: Prevents falls and injuries - Maintain close observation
Rationale: Allows early intervention for unsafe behaviors - Create safe environment
Rationale: Reduces risk of accidents and injury
Desired Outcomes:
- The patient will remain free from injury
- The patient will demonstrate safe behaviors
- The environment will remain hazard-free
Nursing Care Plan 3: Disturbed Sleep Pattern
Nursing Diagnosis Statement:
Disturbed Sleep Pattern related to neurocognitive disruption as evidenced by day-night reversal and irregular sleep-wake cycle.
Related Factors:
- Neurological changes
- Environmental disruptions
- Medications
- Anxiety
- Pain
Nursing Interventions and Rationales:
- Establish a consistent sleep routine
Rationale: Promotes normal circadian rhythm - Manage environmental stimuli
Rationale: Reduces sleep disruptions - Monitor medication timing
Rationale: Optimizes therapeutic effects while minimizing sleep disruption
Desired Outcomes:
- The patient will maintain an appropriate sleep-wake cycle
- The patient will report improved sleep quality
- The patient will demonstrate reduced daytime drowsiness
Nursing Care Plan 4: Impaired Social Interaction
Nursing Diagnosis Statement:
Impaired Social Interaction related to altered thought processes as evidenced by inappropriate social behavior and difficulty communicating.
Related Factors:
- Cognitive impairment
- Communication barriers
- Altered perception
- Emotional lability
- Social isolation
Nursing Interventions and Rationales:
- Use clear, simple communication
Rationale: Promotes understanding and reduces confusion - Encourage family involvement
Rationale: Provides familiar social support - Monitor social interactions
Rationale: Ensures appropriate behavior and safety
Desired Outcomes:
- The patient will demonstrate improved social interactions
- The patient will communicate needs effectively
- Patient will maintain appropriate boundaries
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to altered cognitive state and unfamiliar environment as evidenced by restlessness and expressed concerns.
Related Factors:
- Cognitive changes
- Environmental stressors
- Loss of control
- Fear
- Sensory overload
Nursing Interventions and Rationales:
- Provide calm environment
Rationale: Reduces anxiety triggers - Implement anxiety reduction techniques
Rationale: Helps manage anxiety symptoms - Maintain consistent approach
Rationale: Promotes a sense of security and predictability
Desired Outcomes:
- The patient will demonstrate reduced anxiety levels
- The patient will use effective coping strategies
- The patient will report an improved sense of control
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
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- Keenan CR, Jain S. Delirium. Med Clin North Am. 2022 May;106(3):459-469. doi: 10.1016/j.mcna.2021.12.003. Epub 2022 Apr 4. PMID: 35491066.
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- Mattison MLP. Delirium. Ann Intern Med. 2020 Oct 6;173(7):ITC49-ITC64. doi: 10.7326/AITC202010060. PMID: 33017552.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
