Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Interventions for Delirium

Description of Intervention for Delirium 


Category of Support 
Physiological Support

Interventions

  • Establish/maintain normal fluid and electrolyte balance.
  • Establish/maintain normal nutrition.
  • Establish/maintain normal body temperature.
  • Establish/maintain normal sleep/wake patterns (treat with bright light for two hours in the early evening).
  • Establish/maintain normal elimination patterns.
  • Establish/maintain normal oxygenation (if clients experience low oxygen saturation treat with supplemental oxygen).
  • Establish/maintain normal blood glucose levels.
  • Establish/maintain normal blood pressure.
  • Minimize fatigue by planning care that allows for separate rest and activity periods.
  • Increase activity and limit immobility.
  • Provide exercise to combat the effects of immobility and to "burn off" excess energy.
  • Decrease caffeine intake to help reduce agitation and restlessness.
  • Manage client's discomfort/pain.
  • Promptly identify and treat infections.

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Category of Support 
Communication

Interventions

  • Use short, simple sentences.
  • Speak slowly and clearly, pitching voice low to increase likelihood of being heard; do not act rushed, do not shout.
  • Identify self by name at each contact; call client by his/her preferred name.
  • Repeat questions if needed, allowing adequate time for response.
  • Point to objects or demonstrate desired actions.
  • Tell clients what you want done - not what not to do.
  • Listen to what the client says, observe behaviours and try to identify the message, emotion, or need that is being communicated.
  • Validation Therapy: technique tries to find the reason behind the expressed feeling.
  • Resolution Therapy: attempts to understand and acknowledge the confused client's feelings.
  • Use nonverbal communication alone or in combination with verbal messages.
  • Educate the client (when not confused) and family.

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Category of Support 
Environment

Interventions

  • Reality Orientation: offer orienting information as a normal part of daily care and activities. Repeat information as necessary for the confused person.
  • Provide orienting information and explain the situation, unfamiliar equipment (e.g., monitors, intravenous lines, oxygen delivery devices), the rules/ regulations, plan for care, and the need for safety measures.
  • Remove unfamiliar equipment/devices as soon as possible.
  • Provide call bell and be sure it is within reach. The client should understand its purpose and be able to use it.
  • Use calendars and clocks to help orient client.
  • Limit possible misinterpretations or altered perceptions which may occur due to pictures, alarms, decorations, costumed figures, television, radio and call system.
  • Work with client to correctly interpret his/her environment.
  • Establish a consistent routine, use primary nursing and consistency in caregivers.
  • Bring in items from the client's home, allow the client to wear his/her own clothes.
  • Avoid room changes, especially at night. Put delirious, disruptive clients in a private room if at all possible.
  • Create an environment that is as "hazard free" as possible.
  • Provide adequate supervision of acutely confused/delirious clients.
  • Avoid physical restraint whenever possible; use a sitter or have a family member stay with the client if safety is a concern. If restraints must be used, use the least restrictive of these.
  • Consider moving the client closer to the nurses' station.
  • Environmental manipulations may be appropriate if many clients wander: wandering alarms, exit door alarms, or painting lines on floor in front of exits or rooms you do not want the client to enter. Wandering can also be managed through "collusion", walking with resident, then you or other staff, "invite" him/her to return to ward/facility.
  • Have a plan to deal with disruptive behaviour; keep your hands in sight; avoid "threatening" gestures or movement; remove potentially harmful objects from client, room, and the caregiver's person. Bear in mind that these episodes may not be remembered by clients. If they are remembered, often they are the cause of embarrassment.

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Category of Support 
Sound and Light

Interventions

  • Keep the environment calm and quiet with adequate, but soft, indirect light and limit noise levels.
  • Provide glasses and hearing aides to maximize sensory perception.
  • Consider the use of night lights to combat nighttime confusion.
  • Use music which has an individual significance to the confused and agitated client to prevent the increase in or decrease agitated behaviours.

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Category of Support 
Psychosocial

Interventions

  • Encourage clients to be involved in, and to control, as much of their care as possible.
  • Be sure to allow them to set their own limits, and do not force clients to do things they do not want to, as this is likely to cause disruptive behaviours.Reminiscing can also help increase self-esteem.

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Category of Support 
Social Interaction

Interventions

  • Encourage family and friends to visit, but visits work best when scheduled, and numbers of visitors and lengths of visits should be limited so as not to overwhelm the client.
  • Consider involving the client in programming so as to decrease his/her social isolation (physiotherapy and occupational therapy may be potential options).

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Category of Support 
Other Interventions

Interventions

  • Consult with a Nurse Specialist/Geriatrics or Psychiatry for severe disruptive behaviours, psychosis, or if symptoms do not resolve in 48 hours.
  • Provide reassurance to clients both during and after acute confusion/delirious episodes.
  • Acknowledge client's feelings/fears.
  • Allow clients to engage in activities that limit anxiety.
  • Avoid demanding abstract thinking for delirious clients, keep tasks concrete.
  • Limit choices, and offer decision-making only when clients are capable of making these judgments.

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Category of Support 
Behavioural Management Interventions (for disruptive behaviours seen as part of Acute Confusion

Interventions

  • Changing staffing patterns or altering care routine (including amount/type of touching).
  • One to one supervision.
  • Pay attention to clients.
  • Talk with/counsel clients; give verbal reprimands.
  • Ignore.
  • Removal of client from the situation; time out; seclusion/isolation. Reposition.
  • Positive reinforcement of desired behaviours; removal of reinforcer of undesired behaviour.
  • Restrict activities.
  • Physical or chemical restraint as a last resort.

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Category of Support 
Cognitive and Attentional Limitation Interventions (for disruptive behaviours seen as part of Acute Confusion

Interventions

  • Diversion can be used to distract the client from the disruptive behaviours that she/he is currently engaging in.
  • Divide activities into small steps in order to simplify them and decrease likelihood of causing disruptive behaviours.
  • Determine what triggered or caused the disruptive behaviour, and try to prevent its occurrence.

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Category of Support 
Pharmaceutical Interventions

Interventions

  • In general, limit use of medications (to the extent possible) in clients with acute confusion and disruptive behaviours.
  • Regularly evaluate each medication used and consider discontinuing. If this is not possible, use the minimal number of medications in the lowest effective doses.
  • Monitor for intended and adverse effects of medications.
  • Treat pain in the delirious client; however, be alert for narcotic induced confusion and disruptive behaviours.
  • Avoid medicating clients to control wandering, as medications are likely to make them drowsy and light-headed, increasing the risk for falls
  • Be sure to monitor for side, untoward or paradoxical effects.

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Reprinted with permission.
Rapp, C. G., & The Iowa Veterans Affairs Nursing Research Consortium (1998). Research-Based Protocol: Acute confusion/delirium. In M. G. Titler (Series Ed.). Series on Evidence-Based Practice for Older Adults (pp. 10-13). Iowa City, IA: The University of Iowa College of Nursing Gerontology Nursing Interventions Research Center, Research Dissemination Core.

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