Option 2: Disoriented with stable vital signs

You arrive at the patient's doorway and see her sitting upright in bed, picking at her blanket, and talking to herself. Fortunately, she has left the pulse oximeter on her finger. Her heart rate is 89 beats/minute, and oxygen saturation is 98%. The patient looks up when you come in but doesn't acknowledge you or the nurse. Certainly not good, but it's not looking like a life-threatening emergency either.

The nurse tells you:

• The patient was at her cognitive baseline this morning, was a little “spacey” this afternoon, but is now confused.
• Her urinary catheter was in place for 24 hours after the operation but was removed at shift change.
• Transfer to the bedside commode was possible at dinnertime, but now the patient cannot follow the nurse's directions.
• The patient has not reported pain. She has received only scheduled acetaminophen in the past 8 hours.
• The morning vitals were just completed, and they are normal. The patient's temperature is 37.5°C; blood pressure is 130/75 mm Hg; respiratory rate is 14 breaths/minute.
• The nurse is worried about postoperative urinary retention and would like you to do a quick catheterization.
• The nurse wants to finish charting the patient's intake and output for the shift—that is the main reason she called you. Her supervisor is a stickler for complete charting!

Question: What is the next step in management?

Make your choice, then click on the explanation bubble to reveal the answer.

• Perform a quick in-and-out bladder catheterization to relieve bladder distention. That is what the nurse called you for!
• Perform an examination, including the confusion assessment method.
• Eh, she's stable and probably sundowning. Leave this for the day team, who will be prerounding in an hour.

Delirium can be hyperactive (e.g., agitated), hypoactive (e.g., lethargic), or mixed (e.g., fluctuating between the two). The differential diagnosis is extensive, and clinical clues can help you identify life-threatening etiologies.

Good for you for performing an expedited physical examination. Always examine the patient!

More information...

• During your examination, the patient lets you listen to her heart and lungs but continually swats your hand away from her abdomen. She recognizes her name but does not seem otherwise oriented.
• Your targeted examination of the patient reveals the following:
  • Heart: regular rate, no murmurs, strong bilateral radial pulses
  • Breath sounds: clear and equal bilaterally
  • Abdomen (as best as you can tell): not distended, bowel sounds are present, suprapubic tenderness
  • Skin: warm and dry
  • GCS: 13 (E4 V4 M5)

Hmmm...you still have no clear answers for your confused patient. But you can process what you've gathered so far and assess for red flags. Any red flag requires urgent investigation; the absence of red flags typically allows more time.

What are red flags for a life-threatening cause of altered mental status?

Make your choices, then click on the explanation bubbles to reveal the answers.

• No response to pain
• Decorticate or decerebrate posturing
• Focal neurological deficits
• Absent pupil, corneal, and/or cough reflexes
• Severe vital sign abnormalities
• Severe agitation and/or hallucinations

That's right—all of the above!

Quickly check for red-flag features before diving into a more thorough and nuanced investigation of altered mental status.

Your quick assessment has ruled out any of the major life-threatening causes of altered mental status. Now you can turn your attention to narrowing the extensive differential diagnosis for delirium.

Question: Which diagnostic studies should you order for most patients with presumptive delirium, and why?

Think of the studies you'd like to order and your rationale for ordering them. Make your choices, then click on the explanation bubbles for more information.

• Complete blood count
• Serum glucose
• Basic metabolic panel
• Urinary studies
• Magnesium
• Liver chemistries
• Blood gases
• Serum or urine drug levels
• Head CT without contrast

Good news! The lab results came back at lightning speed. Based on this, you have identified the likely culprit of this patient's confusion—urinary tract infection!

Question: What would you write in the event note?

Now practice the art of good communication by constructing an event note for this patient. This can be done using the familiar “SOAP note” format. What would you write for each of the following sections? Think of your answer, then click the explanation bubble to see a concise, effective example.

• S (subjective)
• O (objective)
• A (assessment)
• P (plan)

Of course, you're going to need to treat that UTI as part of the plan that you're documenting. Check out “UTI in older adults” and “Catheter-associated UTI” to learn more.

And, because your patient's delirium may take longer to clear up than it takes to write the antibiotic order, here are some manageable steps you can take in the meantime:

• Identify the underlying cause.
• Provide supportive care.
• Reorient your patient often.
• Minimize the use of physical restraints.
• Employ delirium prevention measures.

Check out “Delirium” for additional management and prevention strategies.

If you haven't explored the other scenario yet, jump over to “Option 1: Obtunded and unstable.” You can also return to the main module to wrap up “In a fog.”