The nurse identifies that a patient with delirium is at risk for injury. The interventions that would need to be included in the patient's plan of care to address the safety concerns include:
- Immediate assessment by other caregivers, including a physician if available.
- Assessment of patient's condition and medication administration.
- Establishment of an environment for the patient to remain safe and comfortable.
- Careful monitoring of vital signs, including oxygen saturation levels and blood pressure.
- Assess and monitor vital signs every 15 minutes
- Make sure that the patient is receiving sufficient hydration
- Rotate the position of the patient's bed so that they are not lying directly on their back, which can cause pressure on the spinal cord.
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