Psychiatric Mental Health Nursing by Videbeck

21 COGNITIVEDISORDERS 515

APPLICATION OF THE NURSING

PROCESS: DELIRIUM

Nursing care for clients with delirium focuses on

meeting their physiologic and psychological needs and

maintaining their safety. Behavior, mood, and level of

consciousness of these clients can fluctuate rapidly

throughout the day. Therefore, the nurse must assess

them continuously to recognize changes and to plan

nursing care accordingly.

Assessment
HISTORY
Because the causes of delirium are often related to
a medical illness, alcohol, or other drugs, the nurse
obtains a thorough history of these areas. The nurse
may need to obtain information from family mem-
bers if a client’s ability to provide accurate data is
impaired.
Information about drugs should include pre-
scribed medications, alcohol, illicit drugs, and over-
the-countermedications. Although many people per-
ceive prescribed and over-the-counter medications
as relatively safe, combinations or standard doses of
medications can produce delirium especially in older
adults. Box 21-2 lists types of drugs that can cause
delirium. Combinations of these drugs significantly
increase risk.

GENERAL APPEARANCE AND

MOTOR BEHAVIOR

Clients with delirium often have a disturbance of
psychomotor behavior. They may be restless and
hyperactive, frequently picking at bedclothes or mak-
ing sudden, uncoordinated attempts to get out of bed.
Conversely clients may have slowed motor behavior,
appearing sluggish and lethargic with little movement.
Speech also may be affected, becoming less co-
herent and more difficult to understand as delirium
worsens. Clients may perseverate on a single topic
or detail, may be rambling and difficult to follow, or
may have pressured speech that is rapid, forced, and
usually louder than normal. At times clients may call
out or scream especially at night.

MOOD AND AFFECT

Clients with delirium often have rapid and unpre-

dictable mood shifts. A wide range of emotional re-

sponses is possible such as anxiety, fear, irritability,

anger, euphoria, and apathy. These mood shifts and

emotions usually have nothing to do with the client’s

environment. When clients are particularly fearful

and feel threatened, they may become combative to

defend themselves from perceived harm.

THOUGHT PROCESS AND CONTENT

Although clients with delirium have changes in cogni-

tion, it is difficult for the nurse to assess these changes

accurately and thoroughly. Marked inability to sus-

tain attention makes it difficult to assess thought

process and content. Thought content in delirium

often is unrelated to the situation, or speech is illog-

ical and difficult to understand. The nurse may ask

how clients are feeling, and they will mumble about

the weather. Thought processes often are disorga-

nized and make no sense. Thoughts also may be frag-

mented (disjointed and incomplete). Clients may ex-

hibit delusions, believing that their altered sensory

perceptions are real.

SENSORIUM AND

INTELLECTUAL PROCESSES

The primary and often initial sign of delirium is an

altered level of consciousness that is seldom stable and

usually fluctuates throughout the day. Clients usually

are oriented to person but frequently disoriented to

time and place. They demonstrate decreased aware-

Box 21-2

➤ DRUGSCAUSINGDELIRIUM

Anticonvulsants

Anticholinergics

Antidepressants

Antihistamines

Antipsychotics

Aspirin

Barbiturates

Benzodiazepines

Cardiac glycosides

Cimetidine (Tagamet)

Hypoglycemic agents

Insulin

Narcotics

Propranolol (Inderal)

Reserpine

Thiazide diuretics

Adapted from Maxmen, J. S. & Ward, N. G. (2002). Psycho-

tropic Drugs: Fast Facts (3rd ed.). New York: W. W. Norton

& Company. and Mentes, J. C. A nursing protocol to assess

causes of delirium. Journal of Gerontological Nursing,

21 (2), 26 – 30.