Agitation / Delirium 🧠
Clinical guide for managing agitation and delirium. 4AT screening tool, causes, assessment, and management strategies for confused or agitated patients.
📞 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
🕒 26 / 05 / 2026 — 10:13 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: _______