Agitation in a Patient with Delirium and Dementia
Mr. J, a 78-year-old man with moderate Alzheimer's disease, is admitted to the medical unit for a urinary tract infection. On hospital day 2, he becomes acutely agitated, pulling at his IV line and yelling. He is oriented only to self, has a fluctuating level of consciousness, and is visually hallucinating. His daughter reports he was calm at baseline and has no history of agitation. Vitals: HR 112, BP 150/90, T 38.2°C, RR 22. He is not able to follow commands. The nurse must decide how to manage his agitation to ensure safety and prevent worsening of his condition.
1. What is the priority nursing action to manage Mr. J's agitation?
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The priority is to identify and treat the underlying cause of delirium, as delirium is a medical emergency. Mr. J has signs of infection (fever, tachycardia) and possible dehydration or pain. The nurse should:
- Reorient gently and frequently.
- Ensure safety: use the least restrictive measures, such as a bed alarm, low bed, and supervision. Avoid restraints if possible.
- Nonpharmacological interventions: reduce stimulation, maintain a calm environment, use familiar objects, and involve family.
- Assess for pain, constipation, urinary retention, and hypoxia.
- Communicate with the provider about the need to treat the infection and manage agitation without exacerbating delirium.
Antipsychotics may be used cautiously for severe agitation, but only after nonpharmacological measures and treatment of the cause. Benzodiazepines are generally avoided in older adults with delirium due to risk of worsening confusion and falls.
2. The provider orders haloperidol 0.5 mg IM for agitation. What should the nurse consider before administration?
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Before administering haloperidol, the nurse should:
- Assess for QT prolongation risk (obtain ECG if possible, review electrolytes, especially potassium and magnesium).
- Check for Parkinson's disease or Lewy body dementia, as antipsychotics can worsen extrapyramidal symptoms.
- Consider the route: IM haloperidol can be irritating; rotate sites.
- Monitor for side effects: acute dystonia, akathisia, sedation, and neuroleptic malignant syndrome.
- Use the lowest effective dose and only as needed.
- Document target symptoms and monitor response.
The nurse should also continue nonpharmacological interventions and advocate for the smallest dose for the shortest time.