516 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
ness of the environment or situation and instead may
focus on irrelevant stimuli such as the color of the
bedspread or the room. Noises, people, or sensory mis-
perceptions easily distract them.
Clients cannot focus, sustain, or shift attention
effectively, and there is impaired recent and im-
mediate memory (APA, 2000). This means the nurse
may have to ask questions or provide directions re-
peatedly. Even then, clients may be unable to do what
is requested.
Clients frequently experience misinterpretations,
illusions, and hallucinations. Both misperceptions
and illusions are based on some actual stimuli in the
environment: clients may hear a door slam and in-
terpret it as a gunshot or see the nurse reach for an
intravenous bag and think the nurse is about to strike
them. Examples of common illusions include clients
thinking that intravenous tubing or an electrical cord
is a snake and mistaking the nurse for a family mem-
ber. Hallucinations are most often visual: clients “see”
things for which there is no stimulus in reality. Some
clients, when more lucid, are aware that they are ex-
periencing sensory misperceptions. Others, however,
actually believe their misinterpretations are correct
and cannot be convinced otherwise.
JUDGMENT AND INSIGHT
Judgment is impaired. Clients often cannot perceive
potentially harmful situations or act in their own best
interests. For example, they may try repeatedly to
pull out intravenous tubing or urinary catheters; this
causes pain and interferes with necessary treatment.
Insight depends on the severity of the delirium.
Clients with mild delirium may recognize that they
are confused, receiving treatment, and will likely
improve. Those with severe delirium may have no
insight into the situation.
ROLES AND RELATIONSHIPS
Clients are unlikely to fulfill their roles during the
course of delirium. Most regain their previous level
of functioning, however, and have no longstanding
problems with roles or relationships.
SELF-CONCEPT
Although delirium has no direct effect on self-concept,
clients often are frightened or feel threatened. Those
with some awareness of the situation may feel help-
less or powerless to do anything to change it. If delir-
ium has resulted from alcohol, illicit drug use, or
overuse of prescribed medications, clients may feel
guilt, shame, and humiliation or think, “I’m a bad
person; I did this to myself.” This would indicate pos-
sible long-term problems with self-concept.PHYSIOLOGIC AND
SELF-CARE CONSIDERATIONS
Clients with delirium most often experience dis-
turbed sleep–wake cycles that may include difficulty
falling asleep, daytime sleepiness, nighttime agita-
tion, or even a complete reversal of the usual daytime
waking/nighttime sleeping pattern (APA, 2000). At
times, clients also ignore or fail to perceive internal
body cues such as hunger, thirst or the urge to uri-
nate or defecate.Data Analysis
The primary nursing diagnoses for clients with delir-
ium are as follows:- Risk for Injury
- Acute Confusion
Additional diagnoses that are commonly selected
based on client assessment include the following: - Disturbed Sensory Perception
- Disturbed Thought Processes
- Disturbed Sleep Pattern
- Risk for Deficient Fluid Volume
- Risk for Imbalanced Nutrition: Less Than
Body Requirements
Illusion