Night-time Delirium on a 1:7 Orthopaedic Ward
At 02:10 on a 30-bed orthopaedic ward, a 78-year-old woman is day 1 post right hip hemiarthroplasty for a displaced femoral neck fracture. Her Morse Fall Scale score is 65. She has a morphine PCA and at 22:00 received IV diphenhydramine 25 mg for morphine-related itching. Her urinary catheter was removed at 20:00. At 02:10 the bed alarm sounds: she is sitting on the edge of the bed trying to stand to reach the toilet, saying she 'must go now'. She is confused to time and place but follows simple commands. At baseline she walks with a walker and one-person assist. The nurse is caring for seven patients; the nearest colleague is in the next room. The chart documents 'no restraints' and there are no standing sedation orders. Last observations: BP 118/70, HR 92, SpO2 96% on room air, temperature 36.9 °C. She has not voided since catheter removal, and the bladder scanner is two corridors away.
1. List, in order, your immediate actions over the next two minutes, and justify why each comes where it does.
Read the worked answer
Order matters - the hip is the immediate hazard.
- Stay with her and call for help without leaving. Press the call bell and name a colleague ('Room 12, I need you now'). At 24 hours post hemiarthroplasty, a fall or forced weight bearing risks dislocation or periprosthetic fracture.
- Lower the bed to its lowest position and block her movement with your body and hands on her trunk/shoulders - not on the operated hip or leg - guiding her to sit back. Do not attempt to lift her alone.
- Treat the cause of the behaviour, not just the behaviour. She needs to void. Offer a bedpan or urinal now, or assist to a commode once help arrives. The confusion is plausibly driven by a full bladder together with residual diphenhydramine and opioid effect.
- Assess once she is safe: pain score, neurovascular status of the right leg (colour, warmth, pulses, sensation, movement), sedation level, SpO2, blood glucose, temperature, and bladder volume if a scanner can be brought.
- Restore the safety net: bed alarm on, call bell in reach, bed low, clutter cleared, and someone within line of sight while she remains at risk.
Reorienting her and walking away, or giving a sedative, both leave the hazard in place. The clinical reasoning is: hazard first, cause second, documentation and escalation third - not the reverse.
2. What will you escalate, to whom, and with what information? State what you would specifically request.
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Escalate in parallel, not sequentially.
- Nurse in charge, immediately. Seven patients with an acutely delirious, mobilising post-operative patient is not a safe allocation. Ask for a specific, time-bound resource: a colleague to cover your other patients for 30 minutes, cohorting her into a bay in direct line of sight of the desk, or a patient swap. Vague statements ('I'm busy') produce no action; requests do.
- Orthopaedic team (or the local post-operative review pathway): same-night review for new confusion, an order for bladder scanning and possible re-catheterisation, review of the diphenhydramine and opioid regimen, and consideration of delirium precipitants - infection, hypoxia, electrolytes, pain, constipation, urinary retention.
- Pharmacy if analgesia needs rationalising.
Use SBAR with numbers: '78-year-old, day 1 right hemiarthroplasty, Morse 65, diphenhydramine 25 mg at 22:00, now confused and trying to climb out of bed, not voided since catheter removal at 20:00, observations stable, nurse ratio 1:7. I need X by Y time.'
If the request is refused, escalate to the site coordinator or nursing supervisor and document the request, the time, and the response. That record is what makes a later review fair to both the patient and you.
3. What documentation and follow-up plan would make this episode defensible at review, and what actions must be avoided?
Read the worked answer
Document contemporaneously and objectively: the time the alarm first sounded, exactly what you saw (position, words used), your actions in sequence with times, who was called and when they arrived, post-event observations and assessments, whether and how much she voided, and the agreed plan (alarm, hourly rounding, scheduled toileting, review requests). Record the escalation requests you made and the responses received.
Complete an incident report for any fall, near-miss or observation failure - it is a risk-management document, is filed separately from the notes, and is not a disciplinary tool.
Avoid:
- Applying restraints or cot sides - not ordered, and in delirium they increase distress, injury and deconditioning.
- Switching the bed alarm off to 'let her sleep'.
- Giving an unreviewed prn sedative to a delirious post-operative patient - it can deepen delirium and mask deterioration.
- Writing labels instead of facts ('agitated', 'non-compliant') rather than describable behaviour and quoted speech.
- Omitting the staffing context: record that help was requested and what was provided, at the time.
Follow-up plan: delirium screening each shift, bladder and bowel monitoring, analgesia review, hydration, orientation measures, daylight mobilisation with physiotherapy, a documented night-time toileting schedule, and confirmation that the medical team reviewed her.