The confused patient who wants to leave
You are the RN in a 30-bed medical ward at 03:10. Mrs Okafor, 81, was admitted 12 hours ago with a urinary tract infection and new confusion. Her baseline is independent at home with mild cognitive impairment. Overnight she has become agitated, repeatedly trying to climb out of bed and saying she must 'get home to the dog'. Her observations: T 38.4°C, HR 112 irregular, BP 148/86, RR 22, SpO2 94% on room air, GCS 14 (E4 V4 M6), blood glucose 7.8 mmol/L. She has an IV cannula in her left forearm, a urinary catheter, and a fluid balance chart showing 200 mL urine in 6 hours. The ward is short-staffed; the AIN is with another patient who has fallen.
1. Differentiate delirium from her baseline cognitive impairment and identify the likely contributors. What is your immediate priority?
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The key discriminator is acuity and fluctuation. Her confusion developed over 12 hours in the context of infection - that is delirium until proven otherwise, not a progression of her mild baseline impairment. Features supporting delirium: acute onset, agitation, disorientation, fluctuating attention, and a raised temperature with tachycardia.
Likely contributors (multifactorial):
- Infection - UTI with fever and tachycardia.
- Possible sepsis - HR 112, RR 22, T 38.4°C; I would calculate a NEWS2 score and escalate if indicated.
- Dehydration/oliguria - 200 mL in 6 hours is low; consider whether she is drinking and whether the catheter is draining.
- Pain, constipation, urinary retention - common and reversible.
- Medications - review for anticholinergics, opioids, benzodiazepines.
- Environment - unfamiliar ward, night-time, noise, restraints of cannula and catheter.
- Sensory - check glasses and hearing aids.
Immediate priority: safety of the patient and others, plus treating the underlying cause. I would stay with her, call for help, use a low bed and floor mat, avoid physical restraint, and escalate to the medical team for sepsis review and a delirium screen (e.g. 4AT). I would also check for urinary retention and pain.
2. She tries to walk out of the ward. Outline your response, including what you may and may not do, and how you would hand this over.
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What I may do:
- Use verbal de-escalation: calm tone, short sentences, validate her wish to go home, orient her to time and place.
- Offer choices that redirect - 'Let's check on the dog together after the doctor sees you.'
- Involve family or next of kin by phone if consent allows.
- Use environmental measures: low bed, sensor mat, dim lighting, familiar items, continence care.
- Escalate urgently to the registrar and request a review for sedation only if clinically indicated and prescribed.
What I may not do:
- I may not detain her by physical force or lock doors; that is false imprisonment.
- I may not administer sedatives without an order.
- I may not assume she lacks capacity because she is confused. Capacity is decision-specific and must be assessed at the time.
If she lacks capacity for this decision and is at immediate risk, I would follow the local policy for managing a patient attempting to leave, contact the treating team and next of kin, and document everything.
Handover (ISBAR): Identify Mrs Okafor, 81, bed 12. Situation: new agitation, attempting to leave, likely delirium on UTI. Background: admitted 12 hours ago, baseline mild cognitive impairment, independent at home. Assessment: NEWS2 elevated, febrile, tachycardic, oliguric, GCS 14. Recommendation: urgent medical review, sepsis screen, delirium screen, capacity assessment, family contact, and a documented behavioural plan for the night.