# Example Order Sets: Delirium Prevention and Management

Below is an example order set for the prevention and management of delirium in the emergency department. This order set template can be an add-on or incorporated into other emergency department order sets. It emphasizes non-pharmacological, evidence-based recommendations along with age-friendly dosing recommendations.  

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Patient Care Orders 

Diet Order 

Regular Diet 

If significant weight loss, consider liberalizing diet and consult dietitian. 

High Protein High Calorie Diet 

Order modifications for signs or symptoms of possible dysphagia and consider a swallowing assessment by Speech-Language Pathology or other site-appropriate service. 

Pureed Diet 

Thick Fluids: Honey 

Other :___________ 

Nutrition Communication 

Eating: 

Assist as needed. 

Goal: out of bed for meal. 

If less than 50% of meals eaten times 24 hours notify physician/nurse practitioner. 

Offer fluids with every patient interaction. Goal:1.5-2 L/day  or _____ L/day. 

Ensure patient is upright and fully alert during all oral intake and for 30 minutes afterwards. 

Notify physician/ physician assistant/ nurse practitioner if level of consciousness is limiting oral intake or medication administration. 

Swallowing Screen 

Other :___________ 

Activity 

Weight bearing as tolerated. 

Ambulate at least daily, progressing to at least ______ times daily (recommended three times per day). Goal is to maintain pre-hospital mobility. 

Encourage range of motion exercises. 

Fall Risk Assessment and Fall Prevention 

***AVOID restraint use whenever possible *** 

Fall Prevention Risk Assessment. Complete ON ADMISSION, after a fall and with status change. 

Fall Risk Monitoring every 4 hours 

Minimize rail use. 

Bed in low position. 

Call bell/personal items/walking aids/footwear in reach. 

Remind patient to call for help verbally and by writing on patient’s white board if available. 

Comfort rounds every 2-3 hours: toilet; reposition. 

AVOID PHYSICAL AND CHEMICAL RESTRAINTS – use bed alarm. 

Weigh Patient 

On admission 

Daily 

Weekly 

Other :___________ 

Notify physician/ physician assistant/ nurse practitioner if weight loss greater than 5% within the last 6 months including during hospital admission. 

Vital Signs  

- Respiratory rate, pulse, blood pressure, temperature, and oxygen saturation. 

**Please avoid ordering vital signs that disrupt patient sleep at night when possible** 

TID while awake and PRN 

Daily and PRN 

Every ______ hours and PRN; call physician/nurse practitioner to re-evaluate after ______ hours 

Other: _______ 

Intake and Output 

Monitor Intake - Oral (include fluid amount and percentage meals consumed) every shift. 

Bladder Assessment and Management 

Toileting/ Elimination. Goal: Maintain patient’s pre-hospital toileting function. Scheduled toileting every 2 to 3 hours to keep bladder empty. Bedside commode only if necessary. Up to bathroom preferred. 

Indwelling catheters are only recommended for patients with obstruction AND difficulty catheterizing, strict ins and outs, to protect serious perineal/sacral wound and for patient comfort at end of life. 

Discontinue indwelling catheter. 

Bladder scan if no urine output in 8 hours. Notify physician/nurse practitioner of results. 

Bladder Scan-Post Void Residual until 3 consecutive scans are less than 250 mL. Perform within 30 minutes of voiding to determine residual volume. 

In-and-Out Catheter if bladder scan shows volume great than 250 mL and notify physician/ physician assistant/ nurse practitioner. 

Delirium Monitoring and Preventative Measures 

Confusion Assessment Method (CAM) every shift and PRN. If CAM positive, physician/ physician assistant/ nurse practitioner. 

Notify physician/ physician assistant/ nurse practitioner if patient has acute change in their level of consciousness or arousal and/or cognition and/or behaviour. 

Behaviour mapping (in patients with dementia or delirium who have concerning behaviours or expressions). 

Delirium Prevention Measures

Orient patient to place/time each morning and PRN (as appropriate to baseline cognition); ensure updated calendar and white board are visible; glasses on, hearing aids in while awake.  

Optimize environment (low noise,light during the day, low light at night). 

Encourage patient to do own self-care (hygiene, grooming) to maintain independence. 

Ensure patient has access to sensory aids (glasses, hearing aids, dentures). 

Implement non-pharmacological sleep promotion measures (warm milk; warm blankets; hand or foot rub; low light/minimize noise; calm approach; avoid caffeinated beverages). 

Allied Health Referrals 

Consider Pharmacy referral for medication review, paper bag test where home medication use/adherence uncertain, assistance with deprescribing if high risk medications. 

Pharmacy Referral. Reason: ___________ 

Speech Language Pathology. Reason: ___________ 

Dietitian Referral. Reason: ___________ 

Physical Therapy Referral. Reason: ___________ 

Occupational Therapy Referral. Reason: ___________ 

Medications 

Pain Management 

Assess for discomfort at rest and with activity; assess body language especially if patient confused or agitated. Use appropriate pain assessment tools (e.g. visual, numerical, ESAS, or PAINAD for non-communicative/ severely cognitively impaired patients). 

Clinical Communication: Optimize non-pharmacologic pain management, including use of cold or heat, massage, positive distraction and repositioning. 

Monitor and document response to pharmacological/ non-pharmacological strategies for pain; use appropriate pain assessment tool. Notify physician/ physician assistant/ nurse practitioner if pain control sub-optimal or adverse effects noted. 

Acetaminophen 1000 mg PO TID while awake. 

OR 

Acetaminophen 500 mg PO q4h PRN for pain (maximum dose 3 g per 24 hours for patients over age 65, frail or malnourished; maximum dose 2 g per 24 hours for patients with liver disease). 

Diclofenac gel 2.32% BID PRN to affected area, specify: ________ 

Avoid oral or IV NSAID use with concomitant corticosteroids, anticoagulants, or antiplatelets unless other alternatives are not effective and patient can take gastroprotective agent. NSAIDs may increase fluid retention and exacerbate CHF. Avoid use in patients with eCrCl < 30 ,l/min or CKD. May increase risk of acute kidney injury and further renal function decline. 

Ibuprofen 200 mg po QID while awake x 3 days 

Lidocaine patch 5% - Apply 1 patch to skin q12h. Location: ___________. Leave the patch on for up to 12 hours a day, then remove for 12 hours. For postherpetic neuralgia or neuropathic pain. 

Caution with opioids as a potential precipitating factor of delirium, cognitive and other side effects. However untreated pain is also a precipitating factor of delirium. Use lower starting doses in older adults, particularly if opioid naïve and/or vulnerable brain. 

Order non-oral routes if difficulty administering orally BUT be careful to adjust for increased potency as appropriate (eg.parenteral HYDROmorphone can be 2 to 4 times as potent as the equivalent oral dose). 

Consider scheduled dose (with parameters to hold or delay scheduled dose if sedated) if significant cognitive impairment or communication barrier may prevent patient from asking for PRN dose. 

Hydromorphone 0.5 mg PO q4h PRN for pain. 

Hydromorphone 0.2 mg IV/SC q4h PRN for pain. 

Hydromorphone 0.5 mg PO q8h; HOLD IF_____________________ 

Hydromorphone 0.2 mg IV/SC q8h; HOLD IF_____________________ 

Fentanyl 12.5 mcg IV x 1 dose.  

Other: _____________________ 

Bowel Routine 

Stool chart. 

Clinical communication: Maintain usual bowel habits. If no routine, aim for bowel movement daily/every other day. If no bowel movement on Day 1 then give PRN laxative at bedtime; Day 2 escalate use of laxatives (increase frequency or add suppository). 

Notify physician/ physician assistant/ nurse practitioner if patient has not had a bowel movement for 48 hours. 

Polyethylene glycol 3350 17 g PO daily. Mix powder in solution. 

Sennosides 2 tab PO qhs 

Sennosides 1-2 tab PO qhs PRN 

Lactulose liquid 30 mL PO TID PRN 

Glycerin adult 1 supp RECTALLY daily PRN 

Tap water enema RECTALLY daily PRN until adequate elimination if glycerin suppository ineffective after 24 hours. 

**Avoid chronic use of mineral oil and phosphate enemas in older adults given increased risk of adverse effects; if an enema is required, try a tap water enema as a safer alternative** 

Phosphate enema 130 mL RECTALLY x 1 

Antinausea Management 

 Use non-pharmacologic approaches to manage nausea: small meals throughout the day, bland foods, avoid acidic, fatty and spicy foods, consider peppermint tea or diet ginger ale. 

**Avoid dimenhyDRINATE in older patients due to anticholinergic effects and risk of delirium** 

Ondansetron 4 mg PO/IV q8h PRN for nausea 

Other: _____________________