Managing a Patient with Acute Confusion After Surgery

Scenario

A 76-year-old patient, 12 hours post-hip surgery, suddenly becomes confused, restless, and attempts to remove IV lines.
Vital signs: T 37.9°C, HR 96, BP 142/78, RR 22, SpO₂ 93% on 2 L O₂.
They are oriented only to self and do not recognize family.

Question: What are your immediate nursing actions, and how do you differentiate between delirium and other neurological causes?

Best Practice Answer

1. Recognize the Clinical Context:
   Acute confusion in the elderly post-surgery often signals postoperative delirium, but could also reflect hypoxia, infection, pain, or medication effects (especially opioids or sedatives).
   Delirium typically develops within hours to days and is fluctuating in nature.

2. Immediate Nursing Actions:

   • Ensure safety first:
     • Stay with the patient.
     • Lower bed, activate bed alarm, remove hazards.
     • Avoid physical restraints unless absolutely necessary.
   • Assess ABCs and obtain vital signs and O₂ saturation immediately.
   • Apply oxygen if SpO₂ < 94% to rule out hypoxia as a contributor.
   • Perform a focused neurological and pain assessment.

3. Identify Potential Causes:

   • Hypoxia: Check SpO₂, lung sounds, ABG if needed.
   • Infection: Assess temperature, WBC, urine output, and surgical site.
   • Metabolic issues: Review blood glucose and electrolytes.
   • Medication review: Identify new or cumulative sedatives, opioids, or anticholinergics.
   • Urinary retention or constipation: Common reversible triggers.

4. Collaborate and Intervene:

   • Notify the provider and report using SBAR format.
   • Anticipate orders for labs (CBC, electrolytes), urinalysis, and imaging (if neuro cause suspected).
   • Reorient the patient frequently — use clocks, familiar objects, family voice.
   • Minimize stimulation (dim lights, quiet environment).
   • Encourage hydration if not contraindicated.

5. Documentation and Monitoring:

   • Document onset, duration, triggers, and interventions.
   • Monitor for progression to hypoactive or hyperactive delirium.
   • Report any neurological deterioration (unequal pupils, new weakness, speech slurring) as possible stroke indicators.

Real-World Application

This scenario assesses your ability to differentiate delirium from dementia or acute neurological events, a key competency in post-op nursing.
It’s a frequent topic in interviews for med-surg, ortho, and geriatrics units.

Key evaluation points:

• Early identification and safety management
• Recognition of underlying causes
• Clear, calm communication with providers and family

Delirium prevention and management directly correlate with patient safety and reduced readmissions, making this a top-tier clinical skill.

Tip: In interviews, emphasize —
“I assess for reversible causes first — oxygenation, infection, medications — while ensuring patient safety and continuous observation.”
This shows both clinical reasoning and patient-centered care under stress.