MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY

Gerontological Nursing – NUR 326

Possible Nursing Diagnoses and Interventions for persons with Delirium

Nursing Diagnoses / Expected Goals/ Outcomes / Interventions
Acute Confusion r/t physiologic, emotional, or environmental processes / Will be reoriented to environment.
Will be CAM negative. / 1. Identify etiological factors causing delirium.
2. Initiate therapies to reduce or eliminate factors causing the delirium.
3. Monitor neurological status on an ongoing basis using CAM.
4. Provide optimistic, but realistic reassurance.
5. Provide client and family with information about what is happening and what can be expected to occur in the future.
6. Avoid demands for abstract thinking, if client can think only in concrete terms.
7. Limit need for decision making, if frustrating/confusing to client.
8. Encourage visitation by significant others.
9. Recognize and accept the client’s perceptions or interpretation of reality (hallucinations or delusions).
10. State your perception in a calm, reassuring, and nonargumentative manner.
11. Remove stimuli, when possible, that create misperception in a particular client (e.g. pictures on the wall or television).
12. Provide appropriate level of supervision/surveillance to monitor client and to allow for therapeutic actions, as needed.
13. Use physical restraints, as needed.
14. Inform client of person, place, and time, as needed.
15. Provide a consistent physical environment and daily routine.
16. Provide caregivers who are familiar to the client.
17. Use environmental cues (e.g., signs, pictures, clocks, calendars) to stimulate memory, reorient, and promote appropriate behavior.
18. Provide a low-stimulation environment for client in whom disorientation is increased by overstimulation.
19. Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, dentures).
20. Approach client slowly and from the front.
21. Address the client by name when initiating interaction.
22. Reorient client to health care provider with each contact.
23. Communicate with simple, direct, descriptive statements.
24. Provide new information slowly and in small doses, with frequent rest periods.
25. Avoid arguing about false beliefs and reinforcing delusional ideas.
(McCloskey & Bulechek. (2000). Nursing Interventions Classification, pp. 245-247.)
High risk for injury r/t altered ability to interpret the environment / Will be safe, i.e. no falls, no injuries, no elopements. / 1. Identify the safety needs of the client, based on level of physical and cognitive function and past history of behavior.
2. Identify and remove potential dangers in environment.
3. Place identification bracelet on patient.
4. Provide space for safe pacing and wandering.
5. Use protective devices (e.g., side rails, locked doors, fences, gates) to physically limit mobility or access to harmful situations.
6. Use notification devices (e.g. Wanderguard, door alarms, movement alarms) to maintain awareness of client location.
(McCloskey & Bulechek. (2000). Nursing Interventions Classification, pp. 249-250, 311.)
Anxiety r/t misinterpretation of environmental cues
Fear r/t misinterpretation of environmental cues / Prevent anxiety.
Relieve anxiety. / 1. Avoid touch and proximity, if this causes stress or anxiety.
2. Avoid unfamiliar situations, when possible.
3. Provide caregivers that are familiar to the patient.
4. Avoid frustrating patient by quizzing with orientation questions that cannot be answered.
5. Provide cues.
6. Decrease noise levels by avoiding paging systems and call lights that ring or buzz.
7. Limit number of choices patient has to make, so not to cause anxiety.
8. Avoid use of physical restraints.
9. Remove or cover mirrors, if patient is frightened or agitated by them.
10. Administer prn medications for anxiety or agitation.
(McCloskey & Bulechek. (2000). Nursing Interventions Classification, pp. 249-250.)
Self-care deficit r/t memory loss, inattention, poor judgment, difficult language use, poor organization / Will have self-care needs met. / 1. Monitor client’s ability for independent self-care.
2. Monitor client’s need for adaptive devices for personal hygiene.
3. Provide desired personal articles (e.g., deodorant, toothbrush, soap).
4. Provide assistance.
5. Assist client in accepting dependency needs.
6. Use consistent repetition of health routines as a means of establishing them.
7. Encourage client to perform normal ADLs to level of ability.
8. Establish a routine for self-care activities.
9. Maintain privacy.
10. Provide frequent cueing and close supervision, as appropriate.
11. Give one simple direction at a time.
(McCloskey & Bulechek. (2000). Nursing Interventions Classification, pp. 575-577.)
Impaired social interaction r/t memory loss, inattention, poor judgment, difficult language use, poor organization / Will maintain social relationships. / 1. Give positive feedback when patient reaches out to others.
2. Encourage client to change environment, such as going outside or to room.
3. See also Self-esteem disturbance r/t awareness of cognitive deficits.
4. Provide unconditional positive regard.
(McCloskey & Bulechek. (2000). Nursing Interventions Classification, pp. 249-250, 311, 604.)

1