DELIRIUM

A Case Study Presented to the Faculty of College of Health Sciences Education In

Partial Fulfillment of the Requirements in NCM 121N/L

Code: 9071

Submitted by:

Sheila Mae C. Saclot BSN-4

Submitted to:

Majella Gonzales, RN, MAN

February 2022
DEFINITION

Delirium is a serious disturbance in mental abilities that results in confused thinking

and reduced awareness of the environment. The start of delirium is usually rapid within hours
or a few days. Delirium can often be traced to one or more contributing factors, such as a
severe or chronic illness, changes in metabolic balance (such as low sodium), medication,
infection, surgery, or alcohol or drug intoxication or withdrawal.

SIGNS & SYMPTOMS

Signs and symptoms of delirium usually begin over a few hours or a few days. They
often fluctuate throughout the day, and there may be periods of no symptoms. Symptoms tend
to be worse during the night when it's dark and things look less familiar. Primary signs and
symptoms include those below.
Reduced awareness of the environment
This may result in:
✓ An inability to stay focused on a topic or to switch topics
✓ Getting stuck on an idea rather than responding to questions or conversation
✓ Being easily distracted by unimportant things
✓ Being withdrawn, with little or no activity or little response to the environment
Poor thinking skills (cognitive impairment)
This may appear as:
✓ Poor memory, particularly of recent events
✓ Disorientation for example, not knowing where you are or who you are
✓ Difficulty speaking or recalling words
✓ Rambling or nonsense speech
✓ Trouble understanding speech
✓ Difficulty reading or writing
Behavior changes
These may include:
✓ Seeing things that don't exist (hallucinations)
✓ Restlessness, agitation or combative behavior
✓ Calling out, moaning or making other sounds
✓ Being quiet and withdrawn especially in older adults
✓ Slowed movement or lethargy
✓ Disturbed sleep habits
✓ Reversal of night-day sleep-wake cycle
Emotional disturbances
✓ These may appear as:
✓ Anxiety, fear or paranoia
✓ Depression
✓ Irritability or anger
✓ A sense of feeling elated (euphoria)
✓ Apathy
✓ Rapid and unpredictable mood shifts
✓ Personality changes

ETIOLOGY( RISK FACTOR)

Any condition that results in a hospital stay, especially in intensive care or after
surgery, increases the risk of delirium, as does being a resident in a nursing home. Delirium is
more common in older adults.
Examples of other conditions that increase the risk of delirium include:
▪ Brain disorders such as dementia, stroke or Parkinson's disease
▪ Previous delirium episodes
▪ Visual or hearing impairment
▪ The presence of multiple medical problems

MEDICAL MANAGEMENT
• Fluid and nutrition. Fluid and nutrition should be given carefully because the patient
may be unwilling or physically unable to maintain a balanced intake; for the patient
suspected of having alcohol toxicity or alcohol withdrawal, therapy should include
multivitamins, especially thiamine.
• Reorientation techniques. Reorientation techniques or memory cues such as a
calendar, clicks, and family photos may be helpful.
• Supportive therapy. The environment should be stable, quiet, and well-lighted;
sensory deficits should be corrected, if necessary, with eyeglasses or hearing aids;
family members and staff should explain proceedings at every opportunity, reinforce
orientation, and reassure the patient.
 Pharmacotherapy
Delirium that causes injury to the patient or others should be treated with medications.
• Antipsychotics. This class of drugs is the medication of choice in the treatment of
psychotic symptoms of delirium.
• Benzodiazepines. Reserved for delirium resulting from seizures or withdrawal
from alcohol or sedative hypnotics.
• Vitamins. Patients with alcoholism and patients with malnutrition are prone to
thiamine and vitamin B12 deficiency, which can cause delirium.
• Hypnotic, miscellaneous. Agents in this class may be useful in the prevention and
management of delirium (e.g. melatonin, ramelteon).

NURSING MANAGEMENT
Nursing management for a patient with delirium include the following:
✓ Psychiatric interview. The psychiatric interview must contain a description of the
client’s mental status with a thorough description of behavior, flow of thought and
speech, affect, thought processes and mental content, sensorium and intellectual
resources, cognitive status, insight, and judgment.
✓ Serial assessment. Serial assessment of psychiatric status is necessary for determining
fluctuating course and acute changes in mental status.
✓ Providing a safe and supportive environment. For example, prevent excessive noise,
provide consistent caregivers and a consistent care routine, use simple phrases,
provide feeding assistance, encourage early mobilization, decrease or avoid
medication administration after the patient's bedtime, eliminate unnecessary stimuli,
and provide supportive aids such as glasses and hearing aids.
✓ Avoiding use of physical restraints, which are indicated only if medically necessary
and all other alternatives have failed. Restraints can worsen confusion and cause
additional medical problems, such as pressure injuries and other complications of
immobility.
✓ Closely monitoring vital signs Delirium may cause hypertension and tachycardia;
hypoxemia can contribute to delirium.
 NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVES: Disturbed thought That within my 8 1. Assess client’s level of 1. Recognizing these behaviors, GOAL MET
processes related to hours span of care, anxiety and behaviors that nurse may be able to intervene
delusional thinking. client will be able to: indicate the anxiety is before violence occurs. After my 8 hours
increasing. span of care, client
a. Maintain agitation was able to:
at a manageable level 2. Maintain a low level of 2. Because anxiety increases in a
so as not to become stimuli in client’s environment highly stimulating environment. a. Maintain agitation
violent. (low lighting, few people, at a manageable
b. will not harm self or simple decor, low noise level). level so as not to
others. become violent.
3. Have sufficient staff 3. Assistance may be required
available to execute a physical from others to provide for b. No harm to self
confrontation, if necessary. physical safety of client or and others.
primary nurse or both.

4. Remove all potentially 4. In a disoriented, confused

dangerous objects from client’s state, clients may use objects to
environment. harm self or others.

5. Maintain a calm manner with 5. Attempt to prevent frightening

the client. client unnecessarily and provide
continual reassurance and
support.

6. Interrupt periods of unreality 6. Client safety is jeopardized

and reorient. during periods of disorientation;
correcting misinterpretations of
reality enhances client’s feelings
of self-worth and personal
dignity.

7. Use tranquilizing 7. For protection of client and

medications and soft restraints, other during periods of elevated
as prescribed by physician. anxiety.
8. Sit with client and provide 8. Client safety is a nursing
one-to-one observation if priority, and one-to-one
assessed to be actively suicidal. observation may be necessary to
prevent a suicidal attempt.

9. Teach relaxation exercises. 9. To intervene in times of

increasing anxiety.

10. Teach prospective 10. to intervene before violence

caregivers to recognize client occurs.
behaviors that indicate anxiety
is increasing and ways.
HEALTH TEACHINGS
✓ Educate the patient, family, and primary caregivers about future risk factors.
✓ Educate families and patients regarding the etiology and course of disease is an important
role for physicians.
✓ Suggest that family members or friends visit the patient, usually one at a time.
✓ Families may worry that the patient has brain damage or a permanent psychiatric illness.
Providing reassurance that delirium often is temporary and is the result of a medical
condition may be beneficial to both patients and their families.
✓ Make sure that the patient is comfortable.
✓ Provide a calm and structured environment.
✓ Encouraging them to rest and sleep.