Delirium / Encephalopathy

Also Consider:  Behavioral Disturbance, Dehydration, Mood Change, Weakness (General) 

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing:

• Heart Rate lying:

• Heart Rate standing: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Fingerstick glucose (patients with diabetes)

• Alcohol intoxication or drug use (if narcotic overdose is suspected, administer naloxone (Narcan) immediately)

• Not eating or drinking as much as usual

• Acute decline in ADL abilities

• Chills, rigors, or diaphoresis (sweats)

• Eyes:  pupils dilated or constricted, reaction to light

• Respiratory: New cough, trouble breathing, abnormal lung sounds, diminished respirations

• GI: Nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness

• GU: New or worsened incontinence, pain with urination, blood in urine, bladder scan for urinary retention

• Very low urinary output (<30cc/hr)

• Edema

• Unrelieved pain

• Neurological check

• Skin: any new skin condition, i.e., bruising (including potential head trauma), rash, redness suggesting cellulitis, signs of infection around an existing pressure ulcer

• Potential for drug overdose or withdrawal.  For opioid overdose, consider use of naloxone

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness such as: Constipation, Dehydration, Dyspnea, Fever, Low Blood Pressure

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • New onset abnormal neurological signs, or sudden, dramatic change in consciousness

• Notify medical staff & resident representative within the next 16 hours. 

  • Abrupt onset of significant change from usual behavior or mental status with no other significant symptoms

• Notify medical staff on the next business day 

  • Persistent change in behavior or confusion with no other significant symptoms

• Notify medical staff at the next regular rounds 

  • Intermittent or gradual progression of confusion or forgetfulness

4. Implement Management Plan

• Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days

• Offer fluids frequently

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Increase monitoring/supervision (15 minute checks, etc)

• Assess risk for unsafe wandering and falls

• Place on 24-hour report for 2-3 days

• Document symptoms and response to interventions each shift

• Obtain lab results (if ordered), and notify medical as needed of:

  • Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)

  • WBC > 12,000 or neutrophils > 90%

  • Infiltrate or pneumonia on chest x-ray

  • Positive C. Diff

  • Positive flu result on swab

  • Urine results suggest infection and symptoms or signs present (Refer to “UTI” Situation)

• Avoid sedative medications

• Pain management, avoiding over-treatment or under-treatment

• Implement infection control measures if indicated

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, restorative needs

• Update advance directives, if appropriate.

• Review status and plan of care with designated representative daily

Delirium Protocol:

Orientation/ Cognitive Stimulation/ Therapeutic Activities

• Reorient patient during all staff contact, including but not limited to:

• Person: Name, title and position of the staff member

• Year, Month, Day, Date and Time – place large print calendar in room.

• Location: State, City, County, Building, Floor, Room

• (Nurse Only) Illness, Treatments

• Avoid room changes as frequent changes may increase disorientation.

• Provide consistent staff assignments to care for patient as much as possible.

• Cognitively stimulating/ therapeutic activities should be encouraged as appropriate to the patient.

• Encourage family involvement through visiting and by bringing in patient’s personal and familiar objects.

• Turn television off unless it is being actively viewed by patient. (No visitor or staff viewing permitted)

• No conversations in the room that are not directed to or from the patient.

Mobility

• Mobilize as early as possible. Assist with sitting and walking.

• Minimize the use of immobilizing devices such as restraints and indwelling urinary catheters.

Sleep

• No television between 20:00 and 8:00.

• No nighttime awakening for routine vital signs unless clinically indicated.

• Schedule routine medications to avoid nocturnal arousals if possible.

• Turn lights on and open the blinds between 6:00 and 20:00.

• Turn the lights off and close the blinds between 20:00 and 6:00.

•  Offer a backrub, snack, or instrumental music if patient is still awake at 22:00.

Vision/ Hearing

• If patient wears glasses, make sure they are on during the day.

• If patient wears hearing aid(s), make sure they are in operating condition and in place during the waking hours.

• Use a hearing amplifier to communicate with hard of hearing patients.

• Address patient in a low pitch of voice, with adequate volume. (Avoid high-pitched speech)

2025-04-26