New Confusion on Post-Operative Day One
Mrs. G, 78, is on post-operative day 1 after open reduction and internal fixation of a right hip fracture. She lives alone, manages her own medications, and was alert and oriented ×4 on admission. At 0200 the UAP reports that Mrs. G is "trying to climb over the side rail," is picking at her IV and urinary catheter, and does not know where she is. Her daughter arrives at 0700 and says, "This is just her dementia kicking in - put the rails up and give her something to knock her out. She had a hip, she can't be walking." Chart review shows: oxycodone 10 mg every 4 hours (last dose 0100, pain 7/10), diphenhydramine 50 mg at 2200 for sleep, lorazepam 1 mg at 2300 for anxiety, no bowel movement since surgery, bladder scan 650 mL with the catheter draining scant urine, SpO2 93% on room air, temperature 38.2 °C, HR 104.
1. What is your interpretation of Mrs. G's change in mental status, and what will you assess first?
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This is delirium, not dementia. Delirium is acute in onset, fluctuating, and marked by inattention and disorientation with an altered level of consciousness; dementia is insidious and progressive, and orientation is usually preserved until late. She was oriented ×4 on admission, so a new change within 24 hours is a medical emergency in an older adult.
Assess for causes, in order of likelihood and urgency: hypoxia (SpO2 93%), infection (temperature 38.2 °C, HR 104 - think urinary, pulmonary, or surgical site), urinary retention (bladder scan 650 mL with scant drainage suggests a kinked or blocked catheter), unrelieved pain (7/10), constipation, and medication effects. Diphenhydramine and lorazepam are both strongly anticholinergic or sedating and are common culprits.
Perform a full set of vital signs including temperature and pulse oximetry, a neuro check, pain assessment, lung and wound assessment, glucose, bladder scan with catheter inspection, and a bowel assessment. Report to the provider promptly and request a workup.
2. How will you respond to the daughter's request for side rails and sedation, and what alternatives will you implement?
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Acknowledge the daughter's fear - her mother has a hip repair and a fall could be catastrophic - then explain clearly that restraints and sedatives do not treat delirium and usually make it worse. Restraints require a provider order, a face-to-face evaluation, time-limited renewal, and the least restrictive option; using side rails to keep her in bed counts as a restraint and increases injury risk when a patient climbs over them. Sedating an older adult deepens confusion and raises fall and aspiration risk.
Implement non-drug measures: reorient frequently; bring glasses and hearing aids; keep her room quiet and lit appropriately at night; involve the daughter in redirection and presence; treat pain; address the catheter and constipation; remove unnecessary tethers such as an unneeded IV; keep the bed low with a floor mat; use a bed or chair alarm per policy; cluster care to allow sleep; and request a sitter if she remains at risk. Mobilize her with assistance, as ordered, rather than confining her. Document the discussion and interventions.
3. Which of Mrs. G's medications would you question, and what will you report to the provider?
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Question diphenhydramine 50 mg and lorazepam 1 mg. Both are on the Beers list of medications to avoid in older adults: diphenhydramine is strongly anticholinergic and causes confusion, dry mouth, urinary retention, and falls; benzodiazepines worsen delirium and fall risk and are not a treatment for it. Request non-drug sleep measures and a review of both orders.
Oxycodone is appropriate but her pain is 7/10, so the dose and timing need reassessment; she may be both under-treated for pain and over-sedated by the other two drugs. Ask about scheduled acetaminophen as an opioid-sparing option.
Report to the provider: acute delirium with a documented mental status change, temperature 38.2 °C, HR 104, SpO2 93%, bladder scan of 650 mL with scant catheter drainage, no bowel movement, and the medications you are questioning. Request a urine analysis and culture, chest x-ray if indicated, CBC and basic metabolic panel, catheter evaluation for kinking, and a revised medication plan.