Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Practice Recommendations for Delirium
1.2 Nurses should use the diagnostic criteria from the Diagnostic and Statistical Manual (DSM) IV-R to assess for delirium, and document mental status observations of hypoactive and hyperactive delirium.
1.4 Nurses have a role in prevention of delirium and should target prevention efforts to the client‘s individual risk factors.
1.5.1 Consultation/Referral Nurses should initiate prompt consultation to specialized services.
1.5.3 Pharmacological Nurses need to maintain awareness of the effect of pharmacological interventions, carefully review the older adults’ medication profiles, and report medications that may contribute to potential delirium.
1.5.5 Education Nurses should maintain current knowledge of delirium and provide delirium education to the older adult and family.
1.5.7 Behavioural Strategies: Nurses have a role in the prevention, identification and implementation of delirium care approaches to minimize responsive behaviours of the person and provide a safe environment.  Further, it is recommended that restraints should only be used as a last resort to prevent harm to self and others.

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