New Confusion at Shift Change
At 06:45 you arrive for handoff on a long-term care unit. The outgoing technician says, 'Mrs. K in 18 is fine. She was up with me at 05:30 and ate a little breakfast.' Mrs. K is 78, admitted three days ago with a urinary tract infection and started on oral antibiotics yesterday. When you enter, she is sitting on the edge of the bed, trying to stand without her walker, and does not recognize her daughter, who arrived at 06:50. She is picking at her Foley catheter and saying, 'I have to catch the bus.' Vitals: temp 38.9 C, HR 104, BP 148/86, RR 22, SpO2 94% on room air. Her daughter says, 'She was completely herself yesterday.' You have 15 minutes before the morning vitals round and 10 patients.
1. What findings support delirium rather than dementia, and what is the immediate risk?
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This is an acute change in mental status, with fluctuating attention, disorientation, a visual-type delusion ('catch the bus'), and new fever in a patient being treated for a UTI. Dementia is typically gradual and stable from day to day; this is a change from yesterday, which points to delirium. The daughter's report of baseline is the key data, because without it a technician might assume 'she is just confused.'
Immediate risks: falls (trying to stand without her walker), catheter trauma from tugging, and untreated infection or sepsis. Delirium in an older adult with a UTI is a medical concern until proven otherwise.
Reasoning: The technician is not diagnosing. The technician is recognizing a change from baseline, naming the risk, and escalating it.
2. What do you do before and during handoff? Write the SBAR you would give.
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Before handoff: stay with her or ask someone to stay; do not leave her on the edge of the bed. Help her back into bed with the walker within reach and the bed low. Take a full set of vitals, check the catheter for tension and urine color, and note the last antibiotic dose. Call the nurse now, not at 07:00.
SBAR:
- S: 'Mrs. K in 18 has new confusion and a temp of 38.9.'
- B: 'She was herself yesterday. She is on oral antibiotics for a UTI, has a Foley, and uses a walker.'
- A: 'She does not recognize her daughter and tried to stand without her walker. HR 104, BP 148/86, SpO2 94%. She is picking at the catheter.'
- R: 'I am staying with her. Can you come assess her now? Do you want urine tested or a sepsis screen?'
Reasoning: Handoff is not a substitute for escalation. New fever plus delirium in an older adult with a UTI needs a nurse at the bedside, not a note in the report.
3. What safety interventions do you use for the next hour, and what should you not do?
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Do: keep the bed low with brakes on, call light in reach, non-skid footwear, and bed alarm if available and per policy. Reorient simply: 'You are in your room. Your daughter is here.' Do not argue with the delusion. Keep the catheter tubing slack and out of reach. Offer fluids if allowed and monitor vitals and urine output.
Do not: apply restraints without an order, leave her alone in the bathroom, give sedatives or pain medication on your own, or try to 'settle her down' with a medication that is not yours to give.
Reasoning: The goal is to reduce harm while the cause is treated, not to make her quiet. Restraints and sedation can worsen delirium and increase injury risk.