Nursing Diagnoses for Delirium: A Comprehensive Guide for Nurses

Delirium, characterized by an acute disturbance in mental status and cognition, manifests rapidly, often within hours or days. This condition is frequently linked to underlying factors such as dehydration, infections, medication side effects, alcohol withdrawal, dementia, organ failure, severe pain, or the physiological processes associated with dying. Recognizing and addressing delirium promptly is crucial in healthcare settings, and nurses are at the forefront of identifying and managing this complex condition.

Understanding Delirium: Symptoms and Types

Delirium presents with a range of symptoms that can fluctuate in severity. Key indicators include:

• Reduced Awareness: Decreased perception of the environment and surroundings.
• Memory Impairment: Difficulty recalling recent events and forming new memories.
• Disorientation: Confusion regarding time, place, or personal identity.
• Incoherent Speech: Speech that is rambling, illogical, or difficult to understand.
• Restlessness and Agitation: Increased motor activity, pacing, or fidgeting.
• Uncooperativeness and Combativeness: Resistance to care, irritability, or aggressive behavior.
• Social Withdrawal: Decreased interaction with others and reduced responsiveness.
• Psychomotor Retardation: Slowed movements and decreased physical activity.
• Sleep-Wake Cycle Disturbances: Disrupted sleep patterns, insomnia, or excessive daytime sleepiness.

Alt text: Nurse assessing elderly patient for delirium, evaluating cognitive function and orientation in hospital.

Delirium is further categorized into three distinct types, each with unique clinical presentations:

• Hyperactive Delirium: This type is characterized by overt psychomotor agitation, restlessness, anxiety, rapid mood changes, and potential hallucinations or perceptual disturbances. Hyperactive delirium is often easier to identify due to its pronounced symptoms but can pose safety risks and lead to incomplete care if the underlying causes are not addressed promptly.
• Hypoactive Delirium: In contrast, hypoactive delirium presents with decreased psychomotor activity, lethargy, drowsiness, slowed responses, and reduced communication. Patients may appear apathetic or withdrawn, resembling a state of sedation or depression. Hypoactive delirium is often underdiagnosed and can be mistaken for other conditions.
• Mixed Delirium: Patients with mixed delirium exhibit fluctuating symptoms, alternating between periods of hyperactive and hypoactive states. This variability can make diagnosis and management more challenging.

Elderly individuals with pre-existing dementia are particularly vulnerable to delirium, especially in hospital settings. The unfamiliar environment, coupled with factors like medications, surgery, or infections, can significantly increase their risk. Diagnosis of delirium relies on thorough mental status assessments, while physical and neurological examinations are essential to rule out other conditions with similar presentations, such as stroke.

The Crucial Role of Nursing in Delirium Management

Nurses are pivotal in the early detection and management of delirium due to their constant bedside presence and continuous patient monitoring. Their vigilance allows for the prompt recognition of subtle changes in cognitive behavior, especially in inpatient environments. The initial step in addressing delirium involves identifying and treating the root cause. This proactive approach is essential to prevent further cognitive decline and minimize safety risks associated with delirium. Educating family members about the signs and symptoms of delirium empowers them to participate actively in early detection and reporting.

Nursing care plans are indispensable tools for structuring and prioritizing care for patients with delirium. These plans guide nursing assessments and interventions, focusing on both short-term and long-term goals of care. The following sections detail specific nursing diagnoses commonly associated with delirium and outline corresponding care plan examples.

Nursing Care Plans for Delirium: Addressing Key Diagnoses

Acute Confusion

Delirium inherently involves acute confusion, characterized by disorientation and disruptions in cognitive processes.

Nursing Diagnosis: Acute Confusion

Related Factors:

• Alcohol Withdrawal
• Medication Side Effects
• Anesthesia
• Sleep Deprivation
• Advanced Age
• Metabolic Imbalances
• Dementia
• Hypoxemia
• Severe Pain

As Evidenced By:

• Hallucinations
• Fluctuations in Cognition
• Agitation
• Restlessness
• Impaired Decision-Making
• Inability to Follow Instructions

Expected Outcomes:

• The patient will demonstrate orientation to person, place, and time.
• The patient will cooperate with care and assessment procedures.
• The patient will effectively communicate needs and follow simple commands.

Nursing Assessments:

1. Evaluate Electrolyte Levels and Laboratory Results: Abnormalities such as metabolic alkalosis, hyponatremia, hypoglycemia, or indicators of infection can point to underlying causes of delirium. Review electrolyte panels, blood glucose levels, and complete blood counts.

2. Assess Level of Consciousness and Orientation: Regularly assess the patient’s alertness and orientation using standardized tools like the Mini-Mental State Examination (MMSE) or the Confusion Assessment Method (CAM). Simple questions about name, location, date, and situation can provide quick insights.

3. Gather Baseline Behavioral Information from Family: Interview family members or caregivers to establish the patient’s typical behavior patterns and cognitive function. This helps discern the onset and nature of the delirium, identifying deviations from the patient’s norm.

Alt text: Nurse interviewing patient’s family for baseline behavior and medical history to diagnose delirium.

Nursing Interventions:

1. Provide Frequent Reorientation: Regularly reorient the patient to their surroundings, time, and situation. Use clear and simple language, providing reminders of the day, date, and location. Visual aids like calendars and clocks can be helpful.

2. Introduce Familiar Objects: Incorporate familiar objects from home, such as photographs of family members, a favorite blanket, or personal items. These can provide comfort, reduce anxiety, and enhance reality orientation.

3. Maintain a Calm and Reassuring Demeanor: Approach the patient with a calm, gentle, and reassuring tone. Use touch therapeutically, provided it does not escalate agitation. Avoid arguing with the patient or challenging their perceptions, instead, acknowledge their feelings and redirect their attention.

4. Address the Underlying Cause: Collaborate with the healthcare team to identify and treat the underlying cause of delirium. This may involve administering antibiotics for infections, managing pain with analgesics (including opioids if necessary), providing anti-anxiety medications for alcohol withdrawal, or initiating fluid and electrolyte replacement for dehydration.

Impaired Social Interaction

Delirium can lead to impaired social interaction due to altered thought processes and inappropriate behaviors.

Nursing Diagnosis: Impaired Social Interaction

Related Factors:

• Impaired Cognitive Functioning
• Altered Thought Processes
• Biochemical Imbalances

As Evidenced By:

• Persistent Disorientation to Environment
• Extreme Confusion
• Slow or Inappropriate Responses to Questions
• Dysfunctional Interactions with Others
• Inability to Focus Attention
• Agitated Behavior
• Drowsiness

Expected Outcomes:

• The patient will respond appropriately to simple questions.
• The patient will participate in group activities or social settings to the extent of their capabilities.

Nursing Assessments:

1. Assess Availability of a Support System: Determine the presence of family members, spouses, or friends who can provide emotional support and assist with communication. Involve the support system in care planning and interventions.

2. Observe Patient Interactions in Different Environments: Observe the patient’s behavior and interactions with others in various settings, particularly in stimulating environments. Note any signs of agitation, withdrawal, or inappropriate social behaviors. Identify environmental triggers that exacerbate symptoms.

Nursing Interventions:

1. Ensure Medication Adherence: Verify that the patient is receiving medications as prescribed and monitor for potential medication-related causes or exacerbating factors of delirium. Educate family members on proper medication administration if necessary.

2. Create a Calm and Quiet Environment: Minimize environmental stimuli by providing a quiet, private, and non-stimulating space. Reduce noise levels, dim bright lights, and limit unnecessary disruptions. Familiar faces can be comforting; encourage visits from familiar individuals.

3. Establish Routines and Consistent Staff Assignments: Maintain consistent daily routines for activities like meals, hygiene, and sleep. When possible, assign the same nursing staff to care for the patient to foster trust, familiarity, and effective communication.

4. Differentiate Delirium from Dementia: Distinguish between delirium and dementia, as these conditions can co-occur or be mistaken for one another. Delirium is typically acute and reversible, while dementia is chronic and progressive. Recognize that dementia increases susceptibility to delirium.

Risk for Injury

Delirium-related disorientation, confusion, and impaired judgment significantly elevate the risk of accidental injury. Ensuring patient safety is a paramount nursing priority.

Nursing Diagnosis: Risk for Injury

Related Factors:

• Alterations in Cognitive Function
• Disorientation and Confusion
• Unfamiliar Environment

As Evidenced By:

(Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred; interventions are preventative.)

Expected Outcomes:

• The patient’s family or caregivers will implement safety strategies to minimize the risk of injury.
• The patient will remain free from injury throughout the course of care.

Nursing Assessments:

1. Evaluate Mental Status and Cognitive Awareness: Continuously monitor the patient’s mental status and cognitive function for fluctuations that increase injury risk. Document changes in alertness, orientation, and attention.

2. Assess for Sensory-Perceptual Impairments: Identify any sensory deficits, such as impaired vision or hearing, which can exacerbate confusion and increase the risk of falls or accidents. Ensure assistive devices (glasses, hearing aids) are readily available and used.

3. Conduct Environmental Safety Checks: Regularly inspect the patient’s environment for potential hazards. Remove clutter, secure cords, ensure adequate lighting, and address any potential fall risks, such as slippery floors or unsecured rugs. Assess accessibility and safety of personal items and furniture.

Alt text: Nurse ensuring patient safety by adjusting bed height and checking for hazards to prevent injury.

Nursing Interventions:

1. Maintain Close Observation During Agitation or Combativeness: When the patient is agitated or combative, ensure close monitoring. Maintain a safe distance to prevent nurse injury, but remain nearby to intervene if the patient attempts to harm themselves. Restraints are considered a last resort when all other measures fail to ensure safety.

2. Familiarize Patient with Environment: Orient the patient to their surroundings, particularly in unfamiliar settings like hospitals. Explain the layout of the room, the location of the call bell, and how to request assistance.

3. Keep Essential Items Within Reach: Ensure that eyeglasses, hearing aids, and frequently used personal items are within easy reach to minimize frustration and confusion.

4. Administer Antipsychotic Medications as Prescribed: For severely agitated or combative patients who pose a risk to themselves or others, administer prescribed antipsychotic medications, such as haloperidol, to induce sedation and reduce agitation. Monitor for side effects and effectiveness of medication.

Risk for Self-Mutilation

Delirium-induced alterations in cognition can, in rare cases, lead to self-mutilating behaviors.

Nursing Diagnosis: Risk for Self-Mutilation

Related Factors:

• Altered Mental State
• Psychotic Disorder
• Impulsivity
• Dissociation
• Irresistible Urge to Cut Self
• Irresistible Urge for Self-Directed Violence
• Labile Behavior
• Substance Misuse
• Negative Feelings

As Evidenced By:

(Risk diagnoses are not evidenced by signs and symptoms; interventions are preventative.)

Expected Outcomes:

• The patient will refrain from self-harm and remain free from self-inflicted injuries.
• The patient will maintain self-control without reliance on restraints or constant supervision.

Nursing Assessments:

1. Assess Current Cognitive and Behavioral Status: Evaluate the patient’s current mental state and behavior. Agitation, combativeness, anxiety, and impulsivity are indicators of heightened risk for self-harm.

2. Evaluate History of Psychiatric Disorders: Inquire about any pre-existing mental health conditions, such as schizophrenia, borderline personality disorder, or bipolar disorder, as these can increase the complexity of delirium and the risk of self-mutilation. Assess for symptoms like hallucinations, delusions, impulsivity, and depression.

Nursing Interventions:

1. Treat the Underlying Cause of Delirium: Prioritize treating the underlying medical cause of delirium, such as sepsis, alcohol withdrawal, or metabolic imbalances. Address these issues with appropriate medications and treatments as prescribed.

2. Encourage Distraction and Engaging Activities: Provide structured and engaging activities to redirect the patient’s attention and reduce restlessness. Offer simple tasks, puzzles, music, or conversation to provide distraction and a sense of control.

3. Remove Potentially Hazardous Objects: Thoroughly assess the patient’s environment and belongings for any items that could be used for self-harm, such as sharp objects, razors, or medications. Remove these items until the patient’s mental status stabilizes.

4. Employ Calming and Soothing Techniques: Utilize calming techniques to reduce anxiety and agitation. This may include playing soothing music, providing gentle touch (if appropriate), offering a quiet space, or engaging in calming conversation.

5. Utilize Restraints Only When Necessary: If all other interventions fail to ensure patient safety, consider the use of limb restraints as a last resort to prevent self-harm. Follow hospital policy and ethical guidelines regarding restraint use.

Risk for Suicide

The altered mental state associated with delirium raises concerns about both unintentional and impulsive suicidal behaviors.

Nursing Diagnosis: Risk for Suicide

Related Factors:

• Change in Behavior
• Confused State
• Cognitive Dysfunction
• Psychiatric Disorder
• Dysfunctional Thought Processes
• Ineffective Impulse Control
• Access to Weapons
• Substance Misuse
• Chronic Pain
• Terminal Illness

As Evidenced By:

(Risk diagnoses are not evidenced by signs and symptoms; interventions are preventative.)

Expected Outcomes:

• The patient will remain safe and free from self-harm.
• The patient will not gain access to weapons or means of self-harm.

Nursing Assessments:

1. Identify Underlying Causes Increasing Suicide Risk: Determine if the underlying cause of delirium is linked to factors that increase suicide risk, such as pre-existing psychiatric disorders, intractable pain, terminal illness, or substance abuse/withdrawal.

2. Recognize At-Risk Populations: Identify if the patient belongs to any high-risk demographic groups for suicide, including individuals with lower socioeconomic status, older adults, those with a history of abuse or suicide attempts, homosexual youth, or incarcerated individuals.

Nursing Interventions:

1. Monitor for Behavioral and Mood Changes: Closely monitor the patient’s behavior and mood for any signs of increasing suicide risk. Be aware that suicide risk can fluctuate depending on stress levels and thought patterns. Continuous observation is essential, especially when mental status is unstable.

2. Provide Orientation and Reassurance: Frequently reorient the patient to reduce confusion and anxiety. Offer reassurance and a calm presence to decrease distress and potentially suicidal ideation.

3. Monitor Access to Hazardous Items: Closely supervise patients who are disoriented, agitated, or experiencing altered perceptions to prevent access to potentially dangerous items like scissors, knives, razors, or medications that could be used for self-harm.

4. Limit Access to Windows and Exits: Restrict unsupervised access to windows or exits to prevent elopement or potential self-harm attempts. Ensure the patient is not left alone in areas with open windows or unsecured exits while confused or with altered consciousness.

5. Prevent Social Isolation: Minimize social isolation as it can worsen delirium symptoms, confusion, and agitation. Provide frequent supervision and encourage safe socialization if appropriate to the patient’s condition and risk level.

References

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
2. Delirium. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386. Accessed Dec. 4, 2022
3. Bennett, C. (2019). Caring for patients with delirium. Wolters Kluwer Health., Inc.