Delirium Nursing Care Plan

Nursing Diagnosis 1: Altered Perception

Confusion related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by CAM-positive: acute onset, fluctuating course, inattention, plus disorganized thinking or altered LOC; Disoriented to time, place, or situation; Fluctuating attention; cannot follow simple commands or recite months backward; Acute change from baseline cognition reported by family or prior shift; Perceptual disturbance (visual hallucinations, illusions).

Interventions

• Screen with the Confusion Assessment Method (CAM) every shift and PRN with any acute change, per facility protocol.
• Document a specific behavioral description rather than vague labels (e.g., "pulling at IV, attempting to climb out of bed" instead of "agitated").
• Establish and document the patient’s cognitive baseline from family, prior notes, or chart review.
• Work through the PINCH ME precipitant checklist each shift: Pain, Infection, Nutrition, Constipation, Hydration, Medications, Environment.
• Identify and document the subtype each shift: hyperactive, hypoactive, or mixed.
• Review the medication list against Beers Criteria for deliriogenic agents (anticholinergics, benzodiazepines, opioids, H₂ blockers) and surface concerns to the provider team.
• In the ICU, screen with the CAM-ICU (Ely 2001) every shift and pair management with the ABCDEF bundle per facility protocol: Awakening trials, spontaneous Breathing trials, Coordination of analgesia and sedation, Delirium monitoring, Early mobility, and Family engagement.
• In the ventilated ICU patient, coordinate with the provider team to support the lightest effective sedation per facility protocol; per SCCM PADIS 2018, dexmedetomidine or propofol is commonly preferred over benzodiazepines, and paired daily spontaneous awakening trials and spontaneous breathing trials are part of the ABCDEF bundle.
• Reorient at every interaction: state your name, the patient’s name, the location, the date, and why they are here.
• Ensure glasses and hearing aids are on during waking hours.
• Place a visible clock and calendar in the patient’s line of sight; mark the day each morning.
• Encourage early mobility per facility protocol: out of bed to chair for meals, supervised ambulation as tolerated.
• Coordinate with the provider team to support deprescribing of deliriogenic medications identified on Beers review.
• Educate the family that delirium is acute and commonly reversible, that recovery can take days to weeks, and that the behavior is not the patient’s choice.
• Coach the family on simple reorientation phrasing ("You’re in the hospital, today is Tuesday, I’m your daughter") and the value of familiar objects from home.
• Educate the patient during lucid intervals about what is happening and what is being done to address it.
• Notify the provider for any acute change in mental status, new CAM-positive screen, or failure of CAM trend to improve within 72 hours of precipitant treatment.
• Coordinate consultation with geriatrics or psychiatry per facility protocol for persistent, severe, or atypical presentations.

Outcome: CAM trend is monitored and reported as the underlying precipitant is treated; Patient is oriented to person, place, time, and situation when clinical state allows; Patient is able to attend to a 1–2 step command when clinical state allows.

Nursing Diagnosis 2: Impaired Verbal Communication

Fall Risk related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by Fluctuating attention and judgment; Attempting to climb out of bed or remove lines, tubes, drains; Wandering or attempting to leave the unit; Visual hallucinations or illusions; Unsteady gait, lower-extremity weakness from immobility.

Interventions

• Complete a fall-risk assessment (e.g., Morse, Hester Davis) on admission and every shift per facility protocol.
• Round on the patient at least hourly and address the 4 Ps: position, pain, potty, possessions per facility protocol.
• Observe for early signs of escalating agitation: restlessness, picking at sheets, calling out, attempting to disconnect lines.
• Keep the bed in the lowest position with side rails used per facility policy, and call light within reach. Per CMS §482.13(e), a restraint is defined by its effect on the patient: any side-rail configuration (commonly four full rails) that restricts the patient’s freedom to exit the bed meets the regulatory definition of a restraint and requires the corresponding documentation, monitoring, and order.
• Place non-skid footwear on the patient any time they are out of bed.
• Coordinate a 1:1 sitter per facility protocol when available for patients at high risk of self-harm, line removal, or elopement.
• Use bed and chair alarms as adjuncts to direct observation per facility protocol.
• Limit restraint use whenever possible per facility protocol; consider restraints a last resort with documented justification, monitoring, and provider order.
• Cluster cares and keep the room well-lit during the day; minimize at-night interruptions.
• Coordinate placement in a room near the nursing station per facility protocol when fall or elopement risk is high.
• Educate the family on the safety plan and on the importance of not assisting the patient out of bed without staff.
• Coach the family to call for staff if the patient attempts to climb out of bed, remove a line, or leave the room.
• Teach the patient during lucid intervals to use the call light before getting up.
• Notify the provider for any new fall, near-fall, line dislodgement, or elopement attempt.
• If chemical or physical restraint is ordered for imminent safety, follow facility protocol with documented justification, monitoring intervals, and provider reassessment.

Outcome: Fall-risk assessment is completed and updated per facility protocol; Lines, catheters, and other devices remain in place when clinical state allows; Patient remains in protected line-of-sight when clinical state and resources support it, per facility protocol.

Nursing Diagnosis 3: Impaired Peripheral Tissue Perfusion

Sleep Pattern Disturbance related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by Sleep-wake cycle reversal: awake at night, sleeps during the day; Frequent nighttime nursing interruptions for vitals, blood draws, medications; Hospital environmental noise: monitor alarms, hallway conversation, overhead lights; Pain, dyspnea, or urinary urgency triggering nocturnal awakening; Daytime napping reducing nocturnal sleep pressure.

Interventions

• Document the patient’s home sleep routine: bedtime, wake time, nighttime habits, sleep aids.
• Track sleep duration and quality each shift in a sleep log.
• Identify and document specific sleep disruptors (pain, noise, lights, procedures, urinary urgency).
• Cluster nighttime nursing care; coordinate with the provider team to defer non-essential procedures during protected sleep hours (commonly 22:00 to 06:00) per facility protocol.
• Dim overhead lights at night; use bedside task lighting only when needed.
• Minimize alarm volume and hallway noise near the room during nighttime hours per facility protocol.
• Open shades and turn on bright light during the day; encourage out-of-bed activity when clinical state allows.
• Offer warm non-caffeinated drink, back rub, or quiet music as bedtime ritual when appropriate.
• Administer prescribed melatonin or trazodone as ordered per provider direction and facility protocol when non-pharm measures are insufficient.
• Surface concerns about benzodiazepines and diphenhydramine to the provider team when seen on the medication list for sleep.
• Teach the family the rationale for protected sleep hours and ask them to limit nighttime visits.
• Educate the patient and family on the link between sleep deprivation and worsening confusion.
• Coach the patient during lucid intervals on bedtime relaxation techniques: slow breathing, progressive muscle relaxation.
• Notify the provider if sleep remains fragmented despite environmental measures and any ordered adjunct medications.

Outcome: Sleep duration and consolidation are monitored and reported per facility protocol; Patient is awake and engaged during the day when clinical state allows; Patient verbalizes feeling rested when clinical state allows.

Nursing Diagnosis 4: Impaired Urinary System Function

Anxiety related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by Family witnessing acute, dramatic cognitive change in a previously independent patient; Fear that delirium represents permanent decline or new dementia; Distress at hallucinations, agitation, or failure-to-recognize-family; Long hours at the bedside leading to physical and emotional fatigue; Anticipated post-discharge supervision demands.

Interventions

• Assess the family’s understanding of delirium and their current emotional state each shift they are present.
• Identify the primary caregiver(s) and their current support system.
• Assess for signs of fatigue, anticipatory grief, or burnout in the family member at the bedside.
• Provide a calm, non-judgmental presence; allow the family to express fear and frustration.
• Update the family at each shift on the patient’s status, what the team is doing, and the expected timeline.
• Invite the family to participate in reorientation and care activities they are comfortable with.
• Encourage the family to bring familiar objects from home: photos, a favorite blanket, eyeglasses, hearing aids.
• Encourage the family to take breaks, eat regular meals, and sleep at home when possible.
• Educate the family on the typical delirium trajectory: acute onset, fluctuation, commonly resolves with treatment of the cause, can take days to weeks.
• Teach the family practical reorientation phrasing and simple de-escalation techniques.
• Educate the family that delirium behavior (anger, accusations, failure to recognize) is the illness, not the patient.
• Provide written materials about delirium, recovery, and signs to watch for after discharge.
• Coordinate referral to chaplaincy, social work, or palliative care per facility protocol for ongoing family support.
• Coordinate post-discharge planning with case management for home support, respite care, or caregiver resources per facility protocol.

Outcome: Family verbalizes understanding that delirium is acute and commonly reversible; Family identifies and uses at least one coping strategy; Family identifies and uses at least one source of support (chaplaincy, social work, family member).

Nursing Diagnosis 5: Risk For Aspiration

Aspiration Risk related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by Lethargy and reduced level of consciousness during episodes; Impaired swallow during fluctuations in attention; Drowsiness from sedating medications (antipsychotic, opioid); Vomiting or reflux from underlying illness; Position changes during agitation that can compromise airway.

Interventions

• Assess level of consciousness, swallow, and gag reflex before each PO intake.
• Auscultate breath sounds before and after meals; document any new crackles or wet voice and report to the provider team.
• Monitor SpO₂ per facility protocol when sedating medications are administered.
• Observe for clinical aspiration signs during meals: coughing, choking, wet voice, throat clearing, prolonged meal time.
• Maintain head of bed elevation per facility protocol (commonly 30–45° when supine, and 90° during meals and for 30 minutes after when not contraindicated).
• Perform a bedside dysphagia screen (e.g., 3-oz water swallow test) within the RN scope of practice per facility protocol for any patient with altered LOC before initiating PO intake; hold PO and escalate to the provider team if the screen fails.
• Coordinate with the provider team for a formal speech-language pathology (SLP) swallow evaluation when the bedside screen fails, when symptoms persist, or when diet-texture recommendations are needed.
• Provide oral care every 4 hours and after meals per facility protocol.
• If NPO is ordered, provide alternative nutrition (enteral) as ordered per provider direction; do not push PO in a high-risk patient.
• Teach the patient during lucid intervals and family to take small bites, chin-tuck, and rest between bites.
• Educate the family on signs of aspiration to report promptly: cough or choke during meals, new fever, increased congestion, drop in SpO₂.
• Teach the family why the patient is on a specific diet texture or thickened liquids and the harm of overriding the plan.
• Notify the provider for any clinical aspiration event: choking, new desaturation, new pulmonary crackles, fever.
• Coordinate chest imaging and antibiotic administration as ordered per provider direction and facility protocol when aspiration pneumonia is suspected.

Outcome: Aspiration precautions are documented and consistently in place per facility protocol; SpO₂ is monitored and reported within ordered parameters; Lungs are auscultated and findings reported each shift.

Nursing Diagnosis 6: Risk For Injury

Injury Risk related to Delirium: acute confusional state with disturbance of attention, awareness, and cognition that fluctuates over the course of a day; underlying medical condition, intoxication, or withdrawal as evidenced by Fluctuating attention and judgment; Attempting to remove lines, tubes, or drains; Visual hallucinations or illusions; Polypharmacy with sedating or orthostatic-causing agents; Use of physical or chemical restraint per provider order.

Interventions

• Assess line, tube, and drain integrity each shift and PRN with agitation.
• Assess skin integrity each shift, including under any restraint device, per facility protocol.
• Observe for early signs of escalating agitation: restlessness, picking at sheets, calling out, attempting to disconnect lines.
• Use the least restrictive measures first per facility protocol: reorientation, family presence, sitter, environmental modification, before considering restraints.
• When restraints are ordered, follow facility protocol with documented justification, monitoring intervals (commonly q15 minutes for behavioral, q2 hours for non-behavioral), and provider reassessment per CMS §482.13(e).
• Pad or secure lines and tubes to reduce accidental dislodgement; consider mitten-style soft limb holders per facility protocol when clinically indicated.
• Reposition every 2 hours when in bed and provide skin care per facility protocol; check restrained extremities for color, motion, sensation, and pulses per protocol.
• Coordinate with the provider team when chemical restraint (commonly a low-dose antipsychotic per provider order) is being considered; nurses administer as ordered, monitor for adverse effects, and reassess the need each shift.
• Educate the family about why restraints are being used (when ordered), what monitoring is in place, and the plan to discontinue them at the earliest opportunity.
• Teach the patient during lucid intervals not to pull at lines or tubes and why each device is in place.
• Notify the provider for any line, tube, or drain dislodgement; new skin breakdown; or injury related to agitation or restraint.
• Coordinate with the provider team for the earliest possible discontinuation of restraints per facility protocol.

Outcome: Lines, tubes, and drains are monitored and remain in place when clinical state allows; Skin integrity is monitored and reported per facility protocol; Restraint use, when ordered, is documented and reassessed per facility protocol and CMS requirements.

Delirium is an acute, fluctuating disturbance in attention and cognition that carries a mortality approaching 30% in hospitalized elderly and is frequently missed at the bedside, especially the hypoactive subtype. DSM-5-TR criteria: (A) disturbance in attention and awareness; (B) develops acutely over hours-to-days and fluctuates in severity; (C) an additional cognitive disturbance (memory, disorientation, language, perception); (D) A and C are not better explained by a pre-existing or evolving neurocognitive disorder; (E) evidence from history, exam, or labs of an underlying medical, substance, or withdrawal cause. Three clinical subtypes: hyperactive (agitated, restless, hallucinating; most often diagnosed but only ~25%), hypoactive (withdrawn, lethargic, often mistaken for depression; ~50% and worst outcomes), and mixed (~25%). Precipitants are captured by the PINCH ME mnemonic (Pain, Infection, Nutrition, Constipation, Hydration, Medications, Environment) or DELIRIUM (Drugs, Eyes/Ears, Low O₂, Infection, Retention, Ictal, Underhydration/Undernutrition, Metabolic). Predisposing factors include dementia, age > 65, frailty, vision/hearing impairment, and multiple comorbidities. (AGS Delirium Practice Guidelines, 2024; Inouye et al., 2014.)

• CAM screening: q-shift gold standard
• Subtype mix: Hyperactive 25%, hypoactive 50%, mixed 25%
• DSM-5-TR vs CAM: CAM = clinical, DSM = diagnostic
• Non-pharm first: Reorient, sleep hygiene, mobility
• Antipsychotic: Considered for severe agitation per provider order

• Makic, M. B. F., & Martinez-Kratz, M. R. (Eds.). (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier.
• American Geriatrics Society. (2024). 2024 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society.
• Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911–922.
• American Geriatrics Society. (2024). AGS Updated Postoperative Delirium Clinical Practice Guideline.
• Devlin, J. W., Skrobik, Y., Gélinas, C., et al. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Critical Care Medicine, 46(9), e825–e873.
• Ely, E. W., Inouye, S. K., Bernard, G. R., et al. (2001). Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA, 286(21), 2703–2710.