Agitated Client With Delirium on a Medical Unit
A 79-year-old is admitted with a urinary tract infection and dehydration. Overnight the client becomes agitated, pulls at the IV and Foley, and tries to climb over the side rails. The client does not recognize the room and calls the nurse by the name of a deceased spouse. Vital signs: heart rate 104, blood pressure 148/86, respirations 20, temperature 38.1°C, SpO2 95%. Blood glucose is 142 mg/dL. The client has no history of dementia and lives independently. The provider orders 'restraints PRN agitation' and haloperidol 2 mg IM now. The unit is short-staffed, and the client's daughter is at the desk demanding 'something to calm him down.'
1. Differentiate delirium from dementia in this client, and identify the priority reversible causes.
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This presentation is delirium: acute onset over hours, fluctuating attention, disorientation, and a clear precipitant (infection plus dehydration). The client lived independently with no known cognitive decline, which argues against dementia as the cause.
Priority reversible contributors to assess and address:
- Infection: temperature 38.1°C and urinary source; obtain cultures as ordered and start antibiotics.
- Dehydration and electrolyte disturbance: check sodium, potassium, BUN/creatinine, and glucose; replace fluids.
- Pain and urinary retention or constipation: a blocked catheter or full bladder can drive agitation.
- Sensory and environmental factors: missing glasses or hearing aids, unfamiliar room, sleep disruption, and nighttime lighting.
- Medication effects and hypoxia: review the MAR and confirm SpO2.
The nurse's judgment: look for and treat the cause before sedating the symptom.
2. How should the nurse respond to the restraint order and the haloperidol order?
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Restraints: The nurse should not apply restraints as a first-line PRN. Restraints require a time-limited provider order specifying type and duration, face-to-face evaluation within the required timeframe, frequent monitoring, and documentation. Least-restrictive measures must be tried and documented first: a family member or sitter at the bedside, moving the client near the nurses' station, frequent reorientation, glasses and hearing aids, pain control, toileting, and a low bed with a mat.
Haloperidol: The nurse should question the order - verify indication, dose, and baseline ECG/QT interval, and assess for dehydration and electrolyte abnormalities that raise the risk of QT prolongation and extrapyramidal effects. Antipsychotics can be appropriate for severe agitation that threatens safety, but they are not a substitute for treating the infection and dehydration, and they carry risk in older adults.
The nurse advocates for a cause-directed, least-restrictive plan and documents the rationale, the alternatives tried, and the client's response.
3. The daughter insists on restraints. How should the nurse respond, and what safety plan should be implemented?
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Respond with empathy and information: explain that restraints can increase agitation, cause injury, and worsen confusion, and that the team is treating the infection and dehydration that are driving the behavior. Offer the daughter a role - sitting with the client, using familiar objects, and speaking calmly - which often reduces agitation and gives her a sense of control.
Safety plan:
- Move the client to a room visible from the nurses' station; assign a sitter if available.
- Low bed, floor mat, non-skid footwear, and a bed alarm rather than restraints.
- Round frequently and address toileting, thirst, and pain.
- Keep the environment quiet and lit at night; reorient with each contact.
- Involve family and use glasses and hearing aids.
- Reassess mental status each shift and document.
If restraints become unavoidable because of imminent harm, follow policy exactly: obtain the order, complete the face-to-face evaluation, monitor circulation, sensation, and respiratory status at required intervals, release and reposition, and discontinue at the earliest opportunity. The nurse's judgment is that restraints are a last resort with strict safeguards, not a staffing solution.