Nursing Guide to Delirium: Nursing Diagnosis, Interventions, & Care Plans

Delirium Definition 

Delirium is a transient, often reversible neuropsychiatric syndrome marked by disturbances in attention, awareness, and cognition. It typically develops over time and fluctuates throughout the day. In critical care, the prevalence may reach 80%, and postoperative delirium occurs in up to 42% of orthopedic surgical cases (Medscape, 2024).

Delirium Etiology and Epidemiology

Delirium has a multifactorial etiology, frequently involving a combination of medical, environmental, and iatrogenic factors. Common causes include:  

• Alcohol or drug withdrawal
• Hypoxia, hypoglycemia, electrolyte imbalances
• Major surgery, particularly with general anesthesia
• Infections such as pneumonia or urinary tract infection
• Sensory deprivation or overstimulation in hospital settings
• Medication toxicity, including anticholinergics and sedatives

Older adults are particularly vulnerable due to lower physiological reserves and cognitive resilience (Johns Hopkins Medicine, 2025).

There are three types of memory loss:

• Dementia, which is a slow decline in learning abilities, problem-solving, memory, or judgement occurring over weeks to months. It can be caused by health conditions such as Alzheimer’s disease and usually affects the population older than 65.
• Delirium, which is a sudden change in the brain which causes alterations in sleep patterns, mental status, and behaviors. Delirium can be associated with withdrawal from alcohol, drugs, or medications, as well as caused by infections.
• Amnesia, which is memory loss caused by a stroke, head injury, substance abuse, motor vehicle accident, emotional event, or combat. It can be temporary or permanent depending on the severity.

The presence of memory loss may indicate a risk factor for dementia, which affects 10% of the 65 or older U.S. population (Harvard School of Public Health, 2008). Additionally, delirium can be reversible with proper diagnosing, early detection is the key in treatment (Lippmann & Perugula, 2016).

Diagnostic Criteria

Diagnosis is clinical, based on observation and standardized tools.

Key Criteria 

Key criteria include (Medscape, 2024):

• Inattention
• Acute onset and fluctuating course
• Disorganized thinking or altered level of consciousness
• Cognitive or perceptual disturbances not better explained by another condition  

Common Assessment Tools 

Common assessment tools include:

• Confusion Assessment Method (CAM)
• CAM for ICU (CAM-ICU)
• Intensive Care Delirium Screening Checklist (ICDSC)  

Common Signs and Symptoms 

Delirium presents with a range of cognitive, perceptual, and behavioral disturbances that typically develop over a short period and fluctuate in severity throughout the day. Recognizing these symptoms early is essential for prompt intervention and prevention of complications.

Nurses should be particularly vigilant in individuals who are hospitalized, older adults, or have multiple comorbidities, as they may present with either overt agitation or more subtle signs such as withdrawal or lethargy. Other signs and symptoms include:

• Hallucinations or illusions
• Disruption of sleep-wake cycles
• Disorientation to time and place
• Confusion or clouded consciousness
• Fluctuating alertness and attention span
• Disturbance in memory, language, or perception
• Motor abnormalities such as tremors or asterixis
• Mood disturbances such as anxiety, euphoria, or irritability

Red Flags

Red flags are critical warning signs that signal a need for immediate reassessment and potential escalation of care. These symptoms often indicate an acute deterioration in neurological status or an underlying life-threatening condition contributing to delirium. Prompt recognition of these symptoms is essential to reduce the risk of harm and prevent adverse outcomes. Observe for:  

• New or worsening hallucinations or delusions.
• Sudden onset of agitation or extreme withdrawal.
• Emergence of suicidal, homicidal, or aggressive behavior.
• Acute deterioration in attention, awareness, or orientation.
• Self-removal of medical devices or attempts to leave care settings.
• Reversal of the sleep-wake cycle with increased nighttime confusion.

Potential Complications

Delirium can result in serious short- and long-term consequences if not promptly recognized and managed. These can include:

• Falls & Injuries: Impaired awareness and motor instability can result in falls, fractures, or self-harm. Individuals may attempt to get out of bed unassisted or remove medical equipment.
• Aspiration pneumonia: Altered mental status increases the risk of impaired swallowing, leading to aspiration and respiratory infections.
• Malnutrition and dehydration: Delirious individuals may be unable or unwilling to eat and drink adequately, leading to poor intake and worsening cognitive and physical function.
• Pressure injuries: Reduced mobility and fluctuating consciousness increase the risk for skin breakdown, particularly during extended hospital stays.
• Functional Decline: Delirium is associated with longer recovery times, new dependencies in activities of daily living, and institutionalization.
• Long-term Cognitive Impairment: Although traditionally considered reversible, delirium can lead to persistent cognitive deficits and has been linked to accelerated onset of dementia.

Treatments

Pharmacological 

Pharmacologic treatment focuses on managing agitation and addressing underlying causes. Medications should be used cautiously, especially in older adults (Medscape, 2024):

• Antipsychotics may be used for severe agitation or psychotic features. These medications block dopamine receptors but carry risks such as extrapyramidal symptoms, especially in older adults. Use the lowest effective dose for the shortest possible duration.
• Benzodiazepines are reserved for delirium due to alcohol or sedative-hypnotic withdrawal. These should be avoided in most other cases due to the risk of respiratory depression and worsening confusion.
• Vitamins such as thiamine and vitamin B12 are essential in individuals with malnutrition or alcohol use disorder to prevent Wernicke encephalopathy or other deficiency syndromes.
• Melatonin and ramelteon (Rozerem®), a melatonin receptor agonist, have shown some benefit in managing sleep-wake cycle disturbances associated with delirium.  

Non-Pharmacological 

Non-pharmacological treatments include:

• Involve family for reassurance and orientation cues.
• Encourage hydration, nutrition, and early mobilization.
• Use sensory aids such as glasses and hearing aids consistently.
• Maintain regular day-night cycles with natural light exposure during the day and minimal disruption at night.
• Provide a stable, quiet, and well-lit environment. Use orientation tools like clocks, calendars, and family photos.

Surgical

There is no surgical treatment for delirium. Postoperative delirium is common. Nurses should anticipate and monitor symptoms closely after high-risk surgeries, particularly orthopedic or cardiac procedures.

Nursing Management 

Assessment and Interventions 

Mental Status Changes 

• Monitor for waxing and waning levels of awareness throughout shifts.
• Perform frequent orientation checks using tools such as the CAM or CAM-ICU.
• Document specific mental status descriptors (e.g., “unable to maintain attention for 30 seconds” instead of “confused”).
• Collaborate with providers for cognitive assessment tools (e.g., MMSE, Mini-Cog).
• Involve psychiatry in the case of persistent or unclear presentations.

Sleep-Wake Disturbances 

• Monitor the effects of nighttime medications on alertness.
• Create a dark, quiet nighttime environment and limit interruptions.
• Use non-pharmacologic strategies like relaxation techniques or earplugs.
• Collaborate with providers to adjust dosing times of sedatives or stimulants.

Psychosocial and Cultural Considerations 

Psychosocial Support for Delirium 

• Provide emotional reassurance and reorientation: Speak calmly, use the person’s name, and explain where they are and what is happening. This helps reduce fear and can decrease agitation.
• Encourage familiar support: Involve consistent caregivers and allow family visitation to promote a sense of safety and familiarity.
• Address distressing symptoms: If individuals express anxiety, fear, or paranoia, provide a quiet environment and acknowledge their concerns without reinforcing delusions.
• Support post-delirium recovery: Some individuals may report a “blackout” experience. Educate them and their families about what occurred and validate emotional reactions.
• Anticipate memory loss: Offer written discharge instructions and use teach-back methods to ensure understanding of care.

Cultural Considerations 

• Respect family involvement preferences: In some cultures, family presence is vital for emotional and spiritual support. Coordinate care plans that align with cultural expectations.
• Tailor communication styles: Use interpreters when needed. Be aware of cultural norms that influence how confusion or mental status changes are perceived.
• Adapt religious practices safely: If religious rituals (e.g., fasting or prayer times) may impact nutrition or medication schedules, collaborating with spiritual care leaders may be appropriate.
• Recognize stigma: In some cultures, delirium symptoms may be misunderstood as possession or shameful behavior. Provide clear, respectful education to reduce stigma.
• Honor end-of-life customs: If delirium occurs in terminal illness, integrate culturally appropriate end-of-life practices into the care plan.

Home Management 

Self-Care

• Monitor for recurrence of symptoms: Teach caregivers to recognize early signs of confusion, especially after medication changes or infections. Have clear instructions on when to call the provider.
• Ensure hydration and nutrition: Encourage fluid intake and monitor for signs of dehydration. Provide high-protein, nutrient-dense meals.
• Support sleep hygiene: Recommend consistent sleep schedules, avoid overstimulation before bedtime, and minimize nighttime interruptions.
• Continue cognitive support: Use calendars, clocks, and labeled photos in their care setting. Maintain a daily routine with planned activities.
• Rehabilitate gradually: Engage in physical and occupational therapy to rebuild strength and independence post-discharge.

Safety Measures 

• Prevent falls: Remove trip hazards, install grab bars, and use mobility aids as recommended. Monitor ambulation during periods of confusion.
• Secure the environment: Use alarms or door locks to prevent wandering in those with residual disorientation. Avoid leaving individuals unattended.
• Simplify medications: Use pill organizers or pre-filled blister packs to prevent dosing errors, especially if cognitive function is still impaired.
• Limit environmental triggers: Reduce excess noise and avoid overstimulating TV or lighting that may confuse the individual.
• Create an emergency plan: Instruct caregivers on steps to take if acute delirium recurs, including when to call 911 or return to the hospital.

Content Release Date 

4/1/2022

Content Expiration

12/31/2028

Content Contributor

The content for this course was created by Kim Matthews, RN.

Ms. Matthews obtained a nursing degree from Western Kentucky University in 1998. Ms. Matthews possesses over 20 years of nursing experience with over 17 of those in the Skilled Nursing industry. Ms. Matthews has extensive experience in MDS, restorative nursing programs, and nursing management. Ms. Matthews is currently a Post-Acute Care Content writer and subject matter expert for MDS.

Resources

• How is Alzheimer’s Disease Diagnosed? https://www.nia.nih.gov/health/alzheimers-symptoms-and-diagnosis/how-alzheimers-disease-diagnosed
• What is the Prevalence of Delirium, Dementia, and Amnesia in the U.S.? https://emedicine.medscape.com/article/793247-overview#a6
• Patient Education: Dementia (Including Alzheimer’s Disease) https://www.uptodate.com/contents/dementia-including-alzheimer-disease-beyond-the-basics

References

• Johns Hopkins Medicine. (2025). Delirium: Managing your loved one’s care. https://www.hopkinsmedicine.org/health/conditions-and-diseases/
• Medscape. (2024). Delirium. https://emedicine.medscape.com/article/288890-overview