Download Delirium prevention care plan

Delirium prevention
care plan: template
Delirium: diagnosis, prevention
and management
2010
NICE clinical guideline 103
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This delirium prevention care plan accompanies the clinical guideline: ‘Delirium:
diagnosis, prevention and management’ (available online at
www.nice.org.uk/guidance/CG103).
Issue date: 2010
This is a support tool to help people implement NICE guidance on the diagnosis,
prevention and management of delirium. It should be read together with NICE clinical
guideline 103.
It is not NICE guidance.
Implementation of the guidance is the responsibility of local commissioners and/or
providers. Commissioners and providers are reminded that it is their responsibility to
implement the guidance, in their local context, in light of their duties to avoid unlawful
discrimination and to have regard to promoting equality of opportunity. Nothing in the
guidance should be interpreted in a way that would be inconsistent with compliance
with those duties.
National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn, London WC1V 6NA; www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2010. All rights reserved. This
material may be freely reproduced for educational and not-for-profit purposes. No
reproduction by or for commercial organisations, or for commercial purposes, is allowed
without the express written permission of NICE.
NICE clinical guideline 103: Delirium prevention care plan template
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Delirium prevention care plan: template care plan
Use this care plan template to help develop a local resource to aid care planning for
people identified as at risk of delirium, with no indicators of delirium. This template
could be incorporated into your existing care planning documents to ensure that all
aspects of delirium prevention are considered.
Assess patients’ risk of delirium with the NICE ‘Delirium admission assessment’ tool
(available from www.nice.org.uk/guidance/CG103). Attach the completed admission
assessment form to this document.
If the patient becomes at risk of delirium during their stay, attach the local
assessment documentation to this document.
This tailored multicomponent intervention package consists of assessment for
clinical factors that may precipitate delirium along with interventions to address each
of these factors. The package should be delivered by a multidisciplinary team trained
and competent in delirium prevention.
The care plan should be reviewed and updated daily. Make sure that the date and
time that the care plan was created and the care plan number are recorded.
Intervention – this is what the NICE guideline recommends in order to prevent
delirium. If the intervention in sections 1.2 and 2.1 is not applicable, because the
patient does not have the identified clinical factor, write ‘not applicable’ in the action
taken box.
Expected outcome (EO)* – this is what you wanted to achieve from delivering the
intervention to the patient – for example, the patient does not become disorientated,
or does not show any signs of infection. The outcome should be objective.
Action taken* – these are the details of the action you have taken to ensure the
patient receives the intervention. Extra lines have been created for when the action
needs to be undertaken more than once in the day or where multiple actions are
needed.
Completed: signed and dated* – this represents when the actions needed to
deliver the intervention have been completed.
Expected outcome achieved* – this section ensures that the patient’s progress is
reviewed regularly. If the patient’s condition deteriorates or the action taken does not
produce the expected outcome, this should be escalated according to local protocols
and documented in the patient’s notes.
The * headings represent columns that should be completed locally in accordance
with the patient’s needs. This document may need modifying if multiple actions are
needed to deliver an intervention
Using this template for care planning could help support the implementation of
‘Essence of Care: Benchmarks for the care environment’ (Department of Health,
2007).
NICE clinical guideline 103: Delirium prevention care plan template
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Date and time care plan written....................................... Care plan review date and time.........................................Care plan number...........
1.1 General interventions for prevention of delirium
Intervention
Expected outcome
(EO)
Action taken
Completed:
sign and date
Ensure that patients at risk of delirium are
cared for by a team of healthcare
professionals who are familiar to the
person at risk
Avoid moving patients within and
between wards or rooms unless
absolutely necessary
Observe for recent changes or
fluctuations in usual behaviour at least
daily
Assess for all 10 clinical factors that may
precipitate delirium (see 1.2.1 to 1.2.10
below)
If clinical factor is present, implement
recommended intervention and document
in ‘action taken’ box.
If clinical factor is not present, write ‘not
applicable’ in action taken box
NICE clinical guideline 103: Delirium prevention care plan template
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EO achieved?
1.2 Tailored/specific interventions to address clinical factors identified for this person
1.2.1
Person has cognitive
impairment and/or
disorientation
Expected outcome
(EO)
Action taken
Completed:
EO achieved?
sign and date
Person is dehydrated and/or Expected outcome
constipated
(EO)
Action taken
Completed:
EO achieved?
sign and date
Provide appropriate lighting and clear
signage. A clock and calendar should be
easily visible. Consider providing a
24-hour clock in critical care
Talk to the person to reorientate them.
Explain where they are, who they are and
what your role is
Introduce cognitively stimulating activities
(for example, reminiscence)
Facilitate regular visits from friends and
family
1.2.2
Ensure adequate fluid intake – encourage
the person to drink. Consider
subcutaneous or intravenous fluids if
necessary
Take advice if necessary when managing
fluid balance in patients with
comorbidities (for example, heart failure
or chronic kidney disease)
NICE clinical guideline 103: Delirium prevention care plan template
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1.2.3
Person is hypoxic
Expected outcome (EO) Action taken
Completed:
EO achieved?
sign and date
Expected outcome (EO) Action taken
Completed:
EO achieved?
sign and date
Expected outcome (EO) Action taken
Completed:
EO achieved?
sign and date
Assess for hypoxia and optimise oxygen
saturation if necessary, as clinically
appropriate
1.2.4
Person has an infection
Look for and treat infection
Avoid unnecessary catheterisation
Implement infection control procedures in
line with ‘Infection control’ (NICE clinical
guideline 2)
1.2.5
Person has immobility or
limited mobility
Encourage patients to mobilise soon after
surgery
Encourage patients to walk (provide
walking aids if needed – these should be
accessible at all times)
Encourage all patients, including those
unable to walk, to carry out active rangeof-motion exercises
NICE clinical guideline 103: Delirium prevention care plan template
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1.2.6
Person is receiving multiple Expected outcome (EO) Action taken
medications
Completed:
EO achieved?
sign and date
Review medications taking into account
both the type and number of medications
1.2.7
Person is in pain
Expected outcome (EO) Action taken
Completed:
EO achieved?
sign and date
Expected outcome (EO) Action taken
Completed:
EO achieved?
sign and date
Assess for pain
Look for non-verbal signs of pain,
particularly in people with difficultly
communicating (for example, people with
learning difficulties or dementia, and
people on a ventilator or who have a
tracheostomy)
Start and review appropriate pain
management for anyone in whom pain is
identified or suspected
1.2.8
Person is poorly nourished
Follow advice given on nutrition in
‘Nutrition support in adults’ (NICE clinical
guideline 32)
If patients have dentures, ensure they
have their own dentures with them and
that they fit properly
NICE clinical guideline 103: Delirium prevention care plan template
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1.2.9
Person has sensory
impairment
Expected outcome
(EO)
Action taken
Completed:
EO achieved?
sign and date
Expected outcome
(EO)
Action taken
Completed:
EO achieved?
sign and date
Resolve any reversible cause of the
impairment, such as impacted ear wax
Ensure hearing and visual aids are
available to, and used by, patients who
need them and that they are in good
working order
1.2.10 Person has sleep
disturbance1
Avoid nursing and medical procedures
during sleeping hours
Reduce noise to a minimum during sleep
periods
1
For more information on good sleep hygiene, see ‘Parkinson’s disease’ (NICE clinical guideline 35).
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2.1 Person has developed indicators of delirium
Note: Observe for recent changes or fluctuations in usual behaviour at least daily
Intervention

Action taken
Completed: sign and date
Arrange for a healthcare professional trained and competent in the
diagnosis of delirium to do a clinical assessment to confirm
diagnosis using the:
o Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) criteria or short Confusion Assessment Method
(short CAM)
o CAM–ICU for people in critical care or in the recovery
room after surgery

If diagnosis of delirium is confirmed, treat according to ‘Delirium’
(NICE clinical guideline 103)
If distinguishing between the diagnoses of delirium, dementia or
delirium superimposed on dementia is difficult, treat for delirium first
(see ‘Dementia: supporting people with dementia and their carers in
health and social care’ NICE clinical guideline 42)
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Other resources to support learning
The following versions of NICE clinical guideline 103 are available from
www.nice.org.uk/guidance/CG103:

The NICE guideline – all the recommendations.

A quick reference guide – a summary of the recommendations for healthcare
professionals and patient pathway algorithms.

‘Understanding NICE guidance’ – information for patients and carers.
 The full guideline – all the recommendations, details of how they were
developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’,
phone NICE publications on 0845 003 7783 or email [email protected] and
quote reference numbers N2224 (quick reference guide) and/or N2225
(‘Understanding NICE guidance’).
Implementation tools
NICE has developed tools to help organisations implement this guideline, available
from www.nice.org.uk/guidance/CG103

Implementation advice – this provides practical suggestions for action to help
those responsible for planning and implementing the guideline. In particular it
details the ‘whole system’ approach which is required in order to prevent
delirium.

Standard slide set – highlights the key messages from the guideline.

Costing tools – a costing statement giving an indication of the savings and
costs associated with implementation, and a costing template allowing you to
estimate the local costs and savings involved.

Audit support and baseline assessment tool – for monitoring local practice
and helping to identify which areas of practice may need more support, decide
on clinical audit topics and prioritise implementation activities.

Delirium admission assessment: template – a template assessment document
for use when assessing people on admission for delirium.
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
Delirium awareness workshop session plan and slide set. A structured
workshop which can be used locally to raise awareness about delirium and
delirium prevention
Related NICE guidance
Acutely ill patients in hospital. NICE clinical guideline 50 (2007).
Dementia. NICE clinical guideline 42 (2006).
Parkinson’s disease NICE clinical guideline 35 (2006).
Nutrition support in adults. NICE clinical guideline 32 (2006)
Violence. NICE clinical guideline 25 (2005). Contains more information about deescalation techniques
Infection control. NICE clinical guideline 2 (2003)
Acknowledgments
Thank you to the:

members of the National Clinical Guideline Centre

members of the Guideline Development Group

attendees of the planning meeting

members of the External Reference Group who reviewed this tool
Glossary
Multidisciplinary team: a team of healthcare professionals with the different clinical
skills needed to offer complete care to people with complex problems such as
delirium.
Long-term care: residential care in a home that may include skilled nursing care and
help with everyday activities. This encompasses nursing homes and residential
homes.
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