Delirium Nursing Diagnosis and Care Management

Delirium is an emergency wearing the mask of confusion. It comes on fast, the level of consciousness swings, and it almost always points at something physical underneath: infection, a drug, an electrolyte shift, or withdrawal. Find and treat the cause and the mental status follows. Miss it and the patient deteriorates.

What is Delirium?

Delirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period (DSM-IV-TR). It is acute and reversible, and it typically rides on an underlying medical condition, substance intoxication or withdrawal, or medication side effects.

Statistics and Incidences

In a systematic review of 42 cohorts across 40 studies, 10-31% of new hospital admissions met criteria for delirium, and the incidence of developing it during admission ranged from 3-29%. In intensive care units, prevalence may reach as high as 80%. Postoperative delirium runs 5-10% after general surgery and as high as 42% after orthopedic surgery. As many as 80% of patients develop delirium at the end of life.

Delirium occurs at any age but is most common in elderly patients with already compromised mental status. Patients admitted with delirium carry mortality rates of 10-26%. Those who develop it during hospitalization face a mortality rate of 22-76%, with a high death rate in the months after discharge.

Causes

The DSM-IV-TR separates the deliriums by etiology even though they share a common presentation:

• Delirium due to a general medical condition. Systemic infections, metabolic disorders, fluid and electrolyte imbalances, liver or kidney disease, thiamine deficiency, postoperative states, hypertensive encephalopathy, postictal states, and sequelae of head trauma.
• Substance-induced delirium. Toxin exposure or medications, including anticonvulsants, neuroleptics, anxiolytics, antidepressants, cardiovascular drugs, antineoplastics, analgesics, antiasthmatics, antihistamines, antiparkinsonian drugs, corticosteroids, and gastrointestinal medications.
• Substance-intoxication delirium. High doses of cannabis, cocaine, hallucinogens, alcohol, anxiolytics, or narcotics.
• Substance-withdrawal delirium. Reduction or termination of long-term, high-dose use of alcohol, sedatives, hypnotics, or anxiolytics.
• Delirium due to multiple etiologies. More than one medical condition, or a medical condition combined with substance use.

Clinical Manifestations

• Altered consciousness ranging from hypervigilance to stupor or semicoma.
• Extreme distractibility with difficulty focusing attention.
• Disorientation to time and place.
• Impaired reasoning and goal-directed behavior.
• Disturbed sleep-wake cycle.
• Emotional instability: fear, anxiety, depression, irritability, anger, euphoria, or apathy.
• Misperceptions of the environment, including illusions and hallucinations.
• Autonomic signs such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure.
• Incoherent speech.
• Impaired recent memory.

Assessment and Diagnostic Findings

• Complete blood cell count with differential. Infection and anemia.
• Electrolytes. Low or high levels.
• Glucose. Hypoglycemia, diabetic ketoacidosis, hyperosmolar nonketotic states.
• Renal and liver function tests. Renal and liver failure.
• Thyroid function studies. Hypothyroidism.
• Urine analysis. Urinary tract infection.
• Urine and blood drug screen. Toxicological causes.
• Thiamine and vitamin B12 levels. Deficiency states.
• Serum marker. The calcium-binding protein S-100 B may serve as a serum marker; levels run higher in patients with delirium than in those without.

Medical Management

Find and treat the underlying cause first.

• Fluid and nutrition. Give carefully, since the patient may be unwilling or unable to maintain balanced intake. For suspected alcohol toxicity or withdrawal, include multivitamins, especially thiamine.
• Reorientation. Calendars, clocks, and family photos serve as memory cues.
• Supportive therapy. Keep the environment stable, quiet, and well-lighted. Correct sensory deficits with eyeglasses or hearing aids. Have family and staff explain proceedings, reinforce orientation, and reassure the patient.

Pharmacologic Management

Treat delirium that threatens injury to the patient or others.

• Antipsychotics. Drug of choice for the psychotic symptoms of delirium.
• Benzodiazepines. Reserved for delirium from seizures or withdrawal from alcohol or sedative-hypnotics.
• Vitamins. Patients with alcoholism or malnutrition are prone to thiamine and vitamin B12 deficiency, which can cause delirium.
• Hypnotics, miscellaneous. Agents such as melatonin and ramelteon may help prevent and manage delirium.

Nursing Management

Nursing Assessment

• Psychiatric interview. Describe mental status: behavior, flow of thought and speech, affect, thought processes and content, sensorium and intellectual resources, cognitive status, insight, and judgment.
• Serial assessment. Repeated assessment captures the fluctuating course and acute mental status changes.

Nursing Diagnosis

• Disturbed thought processes related to delusional thinking.
• Chronic confusion related to cognitive impairment.
• Impaired verbal communication related to cognitive impairment.
• Risk for injury related to suicidal ideation, illusions, and hallucinations.
• Impaired memory related to cognitive impairment.
• Risk for other-directed violence related to suspiciousness of others.

Nursing Care Planning and Goals

Keep agitation at a manageable level so the client does not become violent, and keep the client from harming self or others.

Nursing Interventions

• Assess anxiety. Watch for behaviors signaling rising anxiety so you can intervene before violence occurs.
• Control the environment. Keep stimuli low (dim lighting, few people, simple decor, low noise); a highly stimulating environment raises anxiety.
• Promote safety. Remove potentially dangerous objects; a disoriented client may use them to harm self or others.
• Get help early. Have enough staff available for a physical confrontation if it becomes necessary.
• Stay calm. Maintain a calm manner, avoid frightening the client, and give continual reassurance and support.
• Reorient. Interrupt periods of unreality and correct misinterpretations; this protects safety and preserves the client's dignity.
• Medicate or restrain as prescribed. Use tranquilizing medications and soft restraints per order during periods of elevated anxiety.
• Observe suicide precautions. Provide one-to-one observation for the actively suicidal client.
• Teach relaxation exercises for use as anxiety rises.
• Teach caregivers to recognize rising anxiety and intervene before violence occurs.

Evaluation

Goals are met when caregivers can name the behaviors that signal rising anxiety and the ways to help the client manage it, and when the client, with caregiver help, controls the impulse toward violence against self or others.

Documentation Guidelines

Document individual findings (contributing factors, interactions, social exchanges, specific behaviors); cultural and religious beliefs and expectations; the plan of care; the teaching plan; responses to interventions and teaching; and progress toward outcomes.