RN Basics

First five minutes

New Confusion or Agitation Algorithm

Safety, a quick neuro exam, then delirium and its causes

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Airway, breathing, glucose, vital signs: what is abnormal?

  • Stay with the patient; protect the airway, lines and drains; call for help (rapid response if unstable)
  • Airway, RR, SpO₂ and work of breathing; EtCO₂ or a blood gas if drowsy
  • Fingerstick glucose now
  • BP, HR and rhythm on the monitor, temperature; compare with the last set and the baseline mental status

Airway at risk, slow or labored breathing, or low SpO₂ → step 2Glucose under 70 mg/dL → step 3Low BP, new arrhythmia or abnormal temperature → step 4Vital signs and glucose acceptable → step 5

2 Hypoxia, hypercapnia or an unprotected airway

  • Call the rapid response team or provider, and RT, now
  • Oxygen to SpO₂ 92–96% (88–92% if at risk of CO₂ retention); head of bed up; suction
  • Blood gas: a high PaCO₂ with drowsiness needs ventilatory support (NIV or intubation, per the provider)
  • Pinpoint pupils or slow breathing on opioids: stop the infusion or PCA; naloxone 0.04–0.4 mg IV, titrated to breathing
  • Not protecting the airway (pooled secretions, weak cough or gag): position, suction, bag-mask if needed; prepare to intubate

Breathing corrected: quick neuro exam → step 5

3 Low glucose: treat now

  • Stop any insulin infusion; dextrose 50% 12.5–25 g IV (25–50 mL), or D10 per protocol
  • No IV access: glucagon 1 mg IM
  • Alcohol use or malnutrition: thiamine 100 mg IV with the dextrose; never delay the glucose for it
  • Recheck in 15 minutes and repeat until over 70; tell the provider; look for why it fell (insulin after feeds stopped, sepsis, liver or kidney failure)

Back to baseline → step 6Still confused → step 5

4 Low BP, new arrhythmia or abnormal temperature

  • MAP under 65 or SBP under 90: call the rapid response team; poor brain perfusion until proven otherwise
  • New arrhythmia: 12-lead ECG; treat per the bradycardia or tachycardia algorithm
  • Fever 38.3 °C or more, or under 36 °C: sepsis or meningitis until proven otherwise; call the provider; see New Fever in the ICU
  • Fever with rigidity or clonus, or a new antipsychotic or serotonergic drug: think NMS or serotonin syndrome; call now
  • BP 180/120 or more with headache, vision change or a neuro sign: stroke, bleed or hypertensive encephalopathy

Next: quick neuro exam → step 5

5 Quick neuro exam: any focal sign?

  • GCS, pupils (size, equality, reaction) and orientation, compared with the documented baseline
  • Face, arm and leg strength on each side, speech, vision and gaze (BE-FAST)
  • Subtle seizure signs: eye deviation, nystagmus, twitching of the face or fingers
  • Ask about headache; note anticoagulants, recent procedures and falls

New focal deficit: face, arm, leg, speech, vision or gaze → step 7Seizure, twitching or gaze deviation → step 8New unequal pupils, headache with vomiting, or a brain injury getting worse → step 9No focal signs → step 10

6 Report and reassess

  • SBAR: when it started, the baseline (dementia, hearing, language), vital signs, SpO₂ or EtCO₂, glucose, temperature
  • Neuro findings, RASS and CAM-ICU, what the cause hunt found and what you gave
  • Ask for: blood gas and labs, a medication review, CT or EEG if indicated, and a safety plan (sitter, orders)
  • Recheck RASS, CAM-ICU and vital signs after each change; a falling GCS or new focal sign means calling again at once

End of this path.

7 Focal deficit: call a stroke code

  • Activate the in-hospital stroke code now; stay with the patient; ask about pausing anticoagulant infusions until the CT
  • Last known well: the last time the patient was seen at baseline, not when the change was found
  • Glucose (treat under 60), NIHSS, IV access, weight; nothing by mouth until a swallow screen
  • CT head without contrast, and CTA for large-vessel occlusion, as fast as possible
  • Before a lytic, BP under 185/110; then follow the Stroke Code algorithm

End of this path.

8 Seizure or possible nonconvulsive status

  • Convulsing: time it; side-lying, suction, oxygen; 5 minutes or more: lorazepam 0.1 mg/kg IV, max 4 mg (Status Epilepticus algorithm)
  • Subtle twitching, gaze deviation, fluctuating alertness or not waking after a seizure: ask for an urgent EEG
  • Check glucose, sodium, calcium, magnesium; look for withdrawal and threshold-lowering drugs (cefepime, imipenem, tramadol, bupropion)
  • Call the provider and neurology; anesthesia or RT if the airway is at risk

Seizure controlled or EEG ordered: hunt the cause → step 11

9 Possible raised ICP or herniation

  • Call the provider and neurosurgery now (rapid response if a pupil is newly dilated); on anticoagulants, suspect a bleed
  • HOB 30°, head midline; keep oxygenation and ventilation normal; avoid hypotension
  • Emergent CT head; pupils and GCS every 15 minutes
  • EVD in place: check the ordered height, leveling at the tragus, clamps and drainage
  • Herniation signs: osmotherapy per order (mannitol 1 g/kg, or 23.4% saline 30 mL centrally); brief hyperventilation to PaCO₂ 30–35

End of this path.

10 RASS, then CAM-ICU: is the patient a danger?

  • RASS first: observe, then voice, then touch; at −4 or −5 the CAM-ICU cannot be done
  • CAM-ICU: acute change or fluctuation, plus inattention (more than 2 errors on SAVEAHAART), plus RASS not 0 or disorganized thinking
  • Quiet and drowsy still counts: hypoactive and mixed delirium are the most common types
  • RASS −4 or −5 with no sedation to explain it: treat as coma; call the provider now (CT, EEG, labs)

Yes: RASS +3 or +4, a danger to self or others → step 12No: delirium, or any change from baseline → step 11

11 Hunt the cause while you call the provider

  • Bedside: pain (CPOT, BPS), full bladder (bladder scan), constipation, hypoxia, sleep loss, restraints and tethers
  • Drugs: new opioids, sedatives, anticholinergics (diphenhydramine, scopolamine), steroids; stopped home alcohol, benzodiazepines or opioids
  • Sepsis: temperature, HR, RR, BP, WBC and lactate; look at lines, lungs, urine and wounds
  • Labs: blood gas (CO₂), sodium, calcium, glucose, BUN and creatinine (uremia); ammonia with liver disease or valproate
  • Brain: nonconvulsive seizures (EEG), new stroke or bleed, rising ICP; dementia and older age lower the threshold

Signs of alcohol, benzodiazepine or opioid withdrawal → step 13Workup under way → step 14

12 Keep the patient and staff safe

  • Call for help (charge nurse; security per policy); one person talks, calmly and briefly; keep your exit clear
  • Protect the airway, lines and drains; remove hazards; bed low; a sitter or family at the bedside
  • Treat pain first: CPOT over 2 or BPS over 5 gets an opioid, then rescore
  • Restraints only as a last resort: provider order (never PRN), least restrictive, frequent checks, removed as soon as safe

Still a danger despite these measures → step 15Safe now: hunt the cause → step 11

13 Withdrawal: treat it, do not just sedate

  • Alcohol or benzodiazepine (tremor, sweating, fast HR, hallucinations): benzodiazepine per protocol, to CIWA-Ar if able to talk, RASS if not
  • Thiamine IV before or with glucose: 100 mg daily, or 200–500 mg every 8 h with Wernicke signs (confusion, ataxia, eye findings); replace magnesium
  • Escalating benzodiazepine doses: call the provider for phenobarbital, or propofol if intubated
  • Opioid withdrawal (yawning, sweating, diarrhea, big pupils): restart and taper the infusion; continue home methadone or buprenorphine

Next: non-drug care → step 14

14 Non-drug care for every patient

  • Reorient often; clock, calendar, glasses and hearing aids; family visits and familiar objects
  • Protect sleep: lights and noise down at night, cluster care; daylight and activity by day
  • Mobilize early; remove catheters, lines and restraints as soon as safe
  • Analgesia first, then the lightest sedation that works; daily SAT; avoid benzodiazepines and anticholinergics

Next: report → step 6

15 When a drug is reasonable

  • PADIS 2018: no routine antipsychotic for delirium; short-term use may help distress or danger
  • Haloperidol 2–5 mg IV or IM per order (0.5–1 mg if older or frail); QTc first and daily; hold for QTc over 500 ms
  • Parkinson disease or Lewy body dementia: no haloperidol; ask the provider for an alternative
  • Ventilated, with agitation blocking weaning or extubation: dexmedetomidine 0.2–0.7 mcg/kg/h (PADIS 2018)
  • Stop the antipsychotic once the danger or distress has passed

Next: hunt the cause → step 11

Drugs in this algorithm

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