Delirium Nursing Care Plans Diagnosis and Interventions
Delirium NCLEX Review and Nursing Care Plans
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.
- Hyperactive delirium – associated with agitation and hypervigilance
- Hypoactive delirium – characterized by drowsiness and apathy
- 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- Being withdrawn from the environment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
- Inability or difficulty remembering words
- Nonsense speech
- Difficulty understanding speech
- Difficulty reading or writing
- Behavioral changes
- Restlessness, agitation, or combative behavior
- Making random sounds such as calling out and moaning
- Sleep disturbance
- Disturbance in circadian rhythm or sleep-wake cycle
- Emotional disturbance
- 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
- Sleep deprivation
- 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
- Parkinson’s disease drugs
- 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:
- General decline in health
- Poor recovery
- Possible need for institutional care
- 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.
- 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
- 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.
- 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 Diagnosis for Delirium
Nursing Care Plan for Delirium 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.
|Nursing Interventions for Delirium||Rationales|
|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 for Delirium 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.
|Nursing Interventions for Delirium||Rationales|
|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 for Delirium 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.
|Nursing Interventions for Delirium||Rationale|
|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.|
Nursing Care Plan for Delirium 4
Nursing Diagnosis: Impaired Memory related to cognitive impairment secondary to delirium as evidenced by disorientation to time, place, person, and circumstances, decreased reasoning ability, decreased attention span, easy distractibility, inability to follow simple instructions, and deterioration in personal care and appearance.
- The patient will be able to re-establish mental and psychological functions.
- The patient’s family members will be able to show an understanding of appropriate care and demonstrate adequate coping skills.
- The patient will be able to achieve functional ability at an optimum level and adapt to the alterations of the environment to compensate for limitations.
|Nursing Interventions for Delirium||Rationale|
|Assess the patient’s overall memory and cognitive function.||The General Practitioner Evaluation of Cognition (GPCOG) and other cognitive assessment tools can be used to determine the patient’s cognitive function. The results of the assessment are used to guide treatment and subsequent evaluation.|
|Examine the patient’s capacity to think and talk clearly, keeping an eye out for signs of confusion, memory lapses, changing from one topic to another, and even the use of words. Also, take note of any articulation issues.||This aids the nurse in detecting any changes in the patient’s mental status, which could signal the condition’s improvement or deterioration.|
|Assess the patient for sensory deprivation, CNS drug use, poor nutrition, dehydration, infection, or other disease processes.||Confusion and a shift in mental status are possible side effects.|
|Perform comprehensive person-centered assessments and interim assessments on the patient on a regular basis.||Assessments should be done at least once every six months to uncover difficulties that will assist the person with delirium in living a complete life.|
|Advise the patient to consider using a calendar or drafting a reminder list.||Written reminders can assist the patient in remembering specific actions.|
|Encourage the patient to do supplementary and alternative therapy such as exercise, guided meditation, and massage.||These activities can aid in the reduction of stress, which can exacerbate memory loss.|
|Assist the patient in putting together a medicine cabinet.||A prescription box can help the patient to remember to take the medication on time and to refill the box.|
|Orient the patient to the environment as needed. Calendars, radio, newspapers, television, and other similar media are also appropriate.||Only patients with delirium benefit from reality orientation treatments to improve their awareness of self and environment.|
|Provide a schedule for the patient to follow. Bathing, grooming, eating, resting, and other cognitive activities should all be included in the routine.||The patient will have fewer episodes of disorientation and cognitive process impairment if they have an organized and predictable list of activities to follow. It also establishes a pattern for the patient to follow while allowing to preserve some autonomy in daily activities.|
|Allow the patient to wander around and gather other stuff within acceptable limits.||Allowing the patient to expend energy wandering or tinkering with other items (within safe and appropriate boundaries) decreases anxiety and stress while increasing feelings of security.|
|Reward the patient with positive encouragement when the patient behaves within acceptable boundaries.||This encourages acceptable behavior and boosts the patient’s self-assurance.|
|Include the patient’s family in the care plan, and let the family know what amount of direction and assistance the patient requires on a daily basis to maintain independence and optimal functioning.||Having the patient’s family understand the patient’s care protocols, the reasoning, and how they affect the patient’s overall well-being.|
|Maintain continuity of care for the patient, provide the same caregivers and avoid room changes.||The disorienting effects of hospitalization can be reduced by maintaining continuity of treatment.|
Nursing Care Plan for Delirium 5
Nursing Diagnosis: Acute Confusion related to cognitive impairment secondary to delirium, as evidenced by lack of motivation to initiate goal-directed behavior, a decline in psychomotor activity, misperceptions, increased agitation, restlessness, and altered level of consciousness.
- The patient will be able to have decreased delirium episodes.
- The patient will be able to have a normal reality orientation and state of consciousness.
- The patient will be able to express an understanding of the contributing factors to the disease.
- The patient will be able to make a lifestyle or behavioral modification to prevent or limit the recurrence of the condition.
- The patient will be able to exhibit proper motor behavior.
- The patient will be able to participate in daily activities (ADLs).
|Nursing Interventions for Delirium||Rationale|
|Identify factors such as substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly patients), toxic substance exposure, traumatic events; change in environment, such as unfamiliar noises, excessive visitors.||The development of a specific plan is aided by baseline data.|
|Assess the patient’s behavior and cognition on a regular basis during the day and night, if needed.||Delirium is always accompanied by an abrupt change in mental status, so knowing the patient’s baseline mental status is crucial when assessing delirium.|
|Assess the patient and report any potential physiological changes such as sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and medications with known cognitive and psychotropic side effects.||These modifications may be causing confusion and needs to be addressed.|
|Monitor the patient’s lab results. Laboratory values should be monitored for hypoxemia, electrolyte imbalances, BUN and creatinine, ammonia levels, serum glucose, indications of infection, and medication levels including peak/trough as needed.||Once acute confusion has been identified, the linked underlying causes must be identified and treated.|
|Assess the severity of the patient’s impairment in orientation, attention span, capacity to follow directions, send and receive communication, and response appropriateness.||This should be done in order to establish the severity of the condition.|
|Determine when agitation, hallucinations, and violent actions occur. Sundown syndrome should be considered.||Late in the afternoon, a phenomenon connected with confusion occurs. The patient is becoming increasingly restless, agitated, and confused. Sleep problems, hunger, thirst, or unmet toileting needs can all cause sundowning.|
|Aid in the treatment of underlying issues such as drug intoxication/abuse, infectious disease, hypoxia, metabolic imbalances, dietary deficiencies, pain management.||To maximize the degree of function and to prevent further deterioration, it is critical to continue with the therapy of the underlying condition.|
|Orient the patient to the environment, staff, and appropriate tasks. Present the facts succinctly and briefly as needed.||Increased patient safety is ensured by increased orientation.|
|Adjust the patient’s sensory exposure. Create a tranquil environment by removing distracting sounds and stimuli.||The disoriented patient may misinterpret increased amounts of visual and auditory stimuli.|
|Encourage family/SO(s) to take part in the reorientation process and provide continuing feedback including current news and family happenings.||The confused patient may not fully comprehend what is going on. The presence of relatives and important others may help the patient relax.|
|Give the patient clear instructions and enough time to respond, communicate, and make decisions.||This type of communication can help to alleviate anxiety in unfamiliar situations.|
|Avoid challenging the patient’s irrational thinking.||Challenges to the patient’s thinking can be interpreted as dangerous, leading to a defensive response.|
|Inform all healthcare staff involved with the patient about the patient’s condition, cognition, and behavioral manifestations.||Recognize that the patient’s erratic cognition and conduct is a symptom of delirium and should not be misinterpreted as a preference for caregivers.|
|Plan appropriate care to allow for a healthy sleep-wake cycle for the patient.||Patients with nocturnal exacerbations face increased problems from delirium, thus disruptions in regular sleep and activity patterns should be avoided.|
|Assist the family and significant others in the development of coping strategies.||The family must allow the patient to do all possible to improve the patient’s level of functioning and quality of life.|
|Educate the family on how to detect early indications of confusion and seek medical treatment.||Early intervention helps to avoid long-term consequences.|
Nursing Care Plan for Delirium 6
Nursing Diagnosis: Anxiety related to cognitive behaviors indicative of fear secondary to delirium, as evidenced by decreased attention span, restlessness, feelings of discomfort, apprehension or helplessness, delusions, and disorganized thought process.
- The patient will be able to express feelings of anxiety.
- The patient will be able to respond to relaxation techniques with a minimal anxiety level.
- The patient will be able to reduce their own anxiety level.
- The patient will be free from anxiety attacks.
|Nursing Interventions for Delirium||Rationale|
|Determine the patient’s anxiety level categorized as mild, moderate, severe, and panic anxiety, according to Hildegard E. Peplau.||Mild anxiety patients will have few or no physiological symptoms of anxiety. The vital indicators should be within normal limits. The patient may appear calm, but may have uneasy symptoms such as “butterflies in the stomach.” The patient with moderate anxiety will appear invigorated, with more lively facial expressions and speech tone. Normal or slightly increased vital signs are possible. The patient may express tension. Elevated vital signs, diaphoresis, urine urgency and frequency, dry mouth, and muscle tension are all indicators of increased autonomic nervous system activity in people with severe anxiety. The patient may have palpitations and chest pain at this point. The patient may be agitated and irritated, and new stimuli may overwhelm or overpower the patient. The sympathetic neurotransmitter released by the autonomic nervous system increases at the panic level of anxiety. The patient becomes pale and hypotensive, and his muscle coordination deteriorates. The patient claims to be entirely out of control and may exhibit a range of behaviors, from combativeness to withdrawal.|
|Determine the patient’s perspective of a stressful circumstance in light of cultural ideas, norms, and values.||Cultural perspectives may influence what the patient thinks is distressing.|
|Assess the patient’s physical responses to anxiety.||Somatoform disorders are characterized by physical symptoms such as pain, nausea, weakness, or dizziness that have no apparent physical basis. Anxiety plays a role in these conditions.|
|Ask the patient “Are you feeling anxious now?” to validate the observations.||Anxiety is a normal physical and psychological response to internal and external life events that is extremely personalized.|
|Recognize the patient’s awareness of anxiety.||The cause of anxiety cannot always be determined, the patient may believe that the symptoms being experienced are fake. Acceptance of the patient’s feelings is communicated by acknowledgment of their feelings.|
|Ensure the patient that he is not alone by using presence, contact with permission, verbalization, and manner to encourage the patient to express or clarify the needs, worries, unknowns, and inquiries.||Being friendly and supportive encourages communication.|
|Introduce the patient to the environment and new experiences or individuals.||The patient’s comfort and anxiety levels may be reduced by being aware of the surroundings. If the patient feels threatened and unable to manage surrounding cues, anxiety may escalate to panic.|
|Interact with the patient in a calm and respectful manner.||The concern of the nurse or health care professional can be passed on to the hypersensitive patient. In a quiet and non-threatening setting, the patient’s sense of stability grows.|
|Accept the patient’s arguments; do not fight or debate.||If the patient’s defenses aren’t threatened, the patient may feel safe and secure enough to examine behavior.|
|Encourage the patient to keep track of any anxiety attacks. Instruct the patient to describe the occurrence as well as the circumstances that preceded and followed it. The patient should keep track of how the anxiety was resolved.||To recognize and explore the elements that cause or reduce anxiety are crucial steps in developing alternate responses. The patient may be completely ignorant of the link between emotional distress and anxiety. If the patient agrees, the log may be shared with the health care provider, who may be able to assist the patient in developing more effective coping skills. Symptoms often convey information to the health care professional about the level of anxiety being experienced.|
|Assist the patient in learning new techniques for lowering anxiety including relaxation, deep breathing, positive visualization, and reassuring self-statements.||The patient can control anxiety in a variety of ways by learning new coping strategies.|
|Assist the patient in improving their problem-solving skills. Emphasize the rational techniques that the patient can employ when suffering anxiety.||Learning to recognize a problem and weigh the options for resolving it might help a patient cope.|
More Delirium Nursing Diagnosis
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. (2022). 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. (2020). 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
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