21 COGNITIVEDISORDERS 517
Outcome Identification
Treatment outcomes for the client with delirium may
include the following:
- The client will be free of injury.
- The client will demonstrate increased orien-
tation and reality contact. - The client will maintain an adequate balance
of activity and rest. - The client will maintain adequate nutrition
and fluid balance. - The client will return to his or her optimal
level of functioning.
Intervention
PROMOTING THE CLIENT’S SAFETY
Maintaining the client’s safety is the priority focus of
nursing interventions. Medications should be used
judiciously because sedatives may worsen confu-
sion and increase the risk for falls or other injuries
(Small, 2000).
The nurse teaches clients to request assistance
for activities such as getting out of bed or going to the
bathroom. If clients cannot request assistance, they
require close supervision to prevent them from at-
tempting activities they cannot perform safely alone.
The nurse responds promptly to calls from clients for
assistance and checks clients at frequent intervals.
If a client is agitated or pulling at intravenous
lines or catheters, physical restraints may be nec-
essary. Use of restraints, however, may increase
the client’s fears or feelings of being threatened so
restraints are a last resort. The nurse first tries other
strategies such as having a family member stay with
the client to reassure him or her.
MANAGING THE CLIENT’S CONFUSION
The nurse approaches these clients calmly and speaks
in a clear, low voice. It is important to give realistic
reassurance to clients such as “I know things are up-
setting and confusing right now, but your confusion
should clear as you get better”(validating/giving in-
formation). Facing clients while speaking helps to
capture their attention. The nurse provides explana-
tions that clients can comprehend, avoiding lengthy
or too detailed discussions. The nurse phrases ques-
tions or provides directions to clients in short, simple
sentences, allowing adequate time for clients to grasp
the content or to respond to a question. He or she per-
mits clients to make decisions as they are able and
takes care not to overwhelm or frustrate them.
The nurse provides orienting cues when talking
with clients such as calling them by name and refer-
ring to the time of day or expected activity. For exam-
ple, the nurse might say, “Good morning, Mrs. Jones.
I see you are awake and look ready for breakfast”
(giving information). Reminding the client of the
nurse’s name and role repeatedly may be necessary
such as “My name is Sheila, and I’m your nurse today.
I’m here now to walk in the hall with you”(reality
orientation). Orienting objects, such as a calendar and
clock, in the client’s room are useful.
Often the use of touch reassures clients and
provides contact with reality. It is important to eval-
uate each client’s response to touch rather than as-
sume all clients will welcome it. A client who smiles
or draws closer to the nurse when touched is re-
sponding positively. The fearful client may perceive
touch as threatening rather than comforting and
startle or draw away.
Clients with delirium can experience sensory
overload, which means more stimulation is coming
into the brain than they can handle. Reducing envi-
ronmental stimulation is helpful because these clients
are distracted and overstimulated easily. Minimizing
environmental noises including television or radio
should calm them. It is also important to monitor
response to visitors. Too many visitors or more than
one person talking at once may increase the client’s
confusion. The nurse can explain to visitors that the
client will best tolerate quiet talking with one person
at a time.
The client’s room should be well lit to minimize
environmental misperceptions. When clients experi-
ence illusions or misperceptions, the nurse corrects
them matter-of-factly. It is important to validate the
client’s feelings of anxiety or fear generated by the
misperception but not to reinforce that mispercep-
tion. For example, a client hears a loud noise in the
hall and asks the nurse, “Was that an explosion?”
The nurse might respond, “No, that was a cart bang-
ing in the hall. It was really loud, wasn’t it? It made
me startle a little when I heard it”(presenting reality/
validating feelings).PROMOTING SLEEP AND
PROPER NUTRITION
The nurse monitors the client’s sleep and elimination
patterns and food and fluid intake. Clients may re-
quire prompting or assistance to eat and drink ade-
quate food and fluids. It may be helpful to sit with
clients at meals or frequently offer fluids. Family mem-
bers also may be able to help clients to improve their
intake. Assisting clients to the bathroom periodically
may be necessary to promote elimination if clients do
not make these requests independently.
Promoting a balance of rest and sleep is impor-
tant if clients are experiencing a disturbed sleep pat-
tern. Discouraging or limiting daytime napping may