Agitation / Delirium 🧠

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📞 Ask

  • New or baseline confusion?
  • Vitals: HR, BP, RR, Temp, SpO₂, glucose
  • Trauma, fall, or head injury?
  • Recent med changes (opioids, sedatives)?
  • Pain, retention, constipation?
  • Anticoagulated?

🧠 Possible Causes (PINCH ME)

  • P – Pain
  • I – Infection (e.g. UTI, pneumonia)
  • N – Nutrition (e.g. glucose, electrolytes)
  • C – Constipation
  • H – Hydration / Hypoxia
  • M – Medication or withdrawal (e.g. opioids, benzos)
  • E – Environment (e.g. sensory deprivation, sleep disruption)

📖 Relevant History

  • Collateral if possible
  • Baseline cognition, admission reason
  • Medication review
  • Falls, trauma, anticoagulation

🩺 Exam

  • A–C assessment, full vitals
  • GCS, pupils, speech, neuro signs
  • Chest, abdo, bladder exam

🧪 Investigations

  • Capillary blood glucose
  • Septic screen if infection suspected
  • ECG if cardiac cause possible
  • Bladder scan if retention likely
  • CTB if ↓ GCS, trauma, anticoag, or neuro signs

💊 Management

  • Reassure and re-orientate
  • Treat cause: pain, glucose, infection, retention
  • Stop unnecessary/sedating meds
  • Pabrinex if Wernicke’s risk
  • Analgesia as needed

🚨 Escalate If

  • GCS drop, focal neuro signs
  • Unsafe agitation
  • No response to initial measures
  • Unclear cause
  • Involve MROC if high risk/sedation needed

📝 Documentation

  • Summarise collateral & baseline
  • Note vitals, findings, GCS, investigations
  • Record meds given/held
  • Plan & escalation

4AT Delirium Screening Tool

Quick assessment for delirium risk

Assessment Result

0 / 12
✅Unlikely delirium

Note Template

Ready-to-use clinical note structure

🕒 20 / 11 / 2025 — 22:40

ATRP re: confusion / agitation
Patient: [age] [sex]
Admission Dx: [reason for admission]
PMHx: [esp. dementia, stroke, psych history]

🧾 Hx:
• Onset & fluctuations
• Triggers: pain, retention, infection, meds
• Collateral from staff/family
• Recent changes to meds (e.g. sedatives)?

🩺 Exam:
• GCS: __  Vitals: HR __ BP __ Temp __ RR __
• Pupils, lateralising signs
• Chest & abdo exam, bladder scan

📋 Impression:
Likely cause: [infection / meds / delirium / SDH]

📌 Plan:
• Septic screen, treat cause
• Remove unnecessary meds
• Pabrinex if concern for Wernicke’s
• Consider stat haloperidol if distressed

👤 [Your Name], [Role]
IMC: _______
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