Nursing care plan for delirium

Introduction to Nursing Care Plan for Delirium

Delirium is a common, serious and challenging condition seen in hospital settings. It is an acute brain disorder characterized by a range of symptoms including confusion, disorientation, attention deficits, delusions and hallucinations.

Assessment

As nurses, we need to assess a patient’s delirium status early and accurately to ensure appropriate management. This assessment includes monitoring and recording the following:

• Overall mental status
• Alertness and attention span
• Fluctuations in cognitive ability
• Suspicious behaviors
• Sleep–wake cycle

Explanation: These assessments provide an overall picture of the patient's mental, physical and emotional health, helping to identify risk factors and trigger points which can increase the risk of delirium.

Nursing Diagnosis

Once the assessment is complete, nursing care plans must be designed to address any issues identified. These should be tailored to the specific needs of each patient and include the following diagnoses:

• Imbalanced nutrition: less than body requirements
• Risk for injury
• Social isolation
• Risk for impaired verbal communication
• Powerlessness

Explanation: The nursing diagnoses listed above will help to identify interventions to improve the patient's health and well-being, such as creating a safe environment, providing adequate nutrition and providing social support.

Outcomes

Nursing goals should be established based on the nursing diagnosis and individualized plan of care. Common goals involve relieving symptoms, restoring function, improving quality of life and preventing recurrence. Examples of potential goals include:

1. Reduce risk of harm from delirium
2. Restore or maintain optimal functional level
3. Provide comfort measures
4. Improve coping strategies
5. Promote safety
6. Strengthen family communication

Explanation: Goals should be realistic and achievable in order to maximize the likelihood of success.

Interventions

A variety of therapeutic interventions may be implemented to address the challenges of delirium. These include:

• Monitoring vital signs
• Preventing falls
• Administering medications as prescribed
• Creating a calming environment
• Encouraging family involvement
• Providing supportive care

Explanation: Interventions should be adapted to meet the individual needs of each patient and adjusted as needed over time.

Rationales

In order to understand why these interventions are beneficial, it is essential to consider the rationale behind each one. These rationales may include:

• Promoting comfort and relaxation
• Limiting environmental stimulation
• Increasing patient’s sense of safety
• Reducing confusion and disorientation
• Supporting cognitive and functional abilities

Explanation: By considering the rationale behind each intervention, nurses can better understand how each intervention may benefit the patient and support outcomes.

Evaluation

Once the interventions have been implemented, their effectiveness should be evaluated. Evaluation methods may include:

• Patient self-reports
• Observation of symptoms
• Medical test results
• Family reports

Explanation: By evaluating the effectiveness of interventions, nurses can ensure that they are meeting the needs of their patients and adjusting tactics as necessary.

Conclusion

Delirium is a serious, complex condition which affects both physical and mental wellbeing. To ensure that patients receive the best possible care, it is essential for nurses to develop an accurate assessment, establish realistic goals and implement effective interventions. By evaluating outcomes on an ongoing basis, nurses can ensure that all patients receive timely, appropriate care.

FAQs

• What is delirium?
  Delirium is a brain disorder characterized by confusion, disorientation, attention deficits and other cognitions disturbances.
• How can nurses assess delirium?
  Nurses should assess mental status, alertness, fluctuations in cognitive ability, sleep-wake cycle as well as suspicious behaviors.
• What are some typical nursing diagnoses for delirium?
  Typical nursing diagnoses for delirium include imbalanced nutrition: less than body requirements, risk for injury, social isolation, risk for impaired verbal communication, and powerlessness.
• What interventions can help manage delirium?
  Interventions to manage delirium include monitoring vital signs, reducing environmental stimuli, encouraging family involvement, administering medications as prescribed, promoting comfort and relaxation, and providing supportive care.
• How can nurses evaluate delirium interventions?
  Nurses should evaluate delirium interventions using patient self-reports, observation of symptoms, medical test results, and family reports.