INTRODUCTION:

ICU delirium is an acute and sudden disturbance in mental status leading to impaired attention, awareness, and cognition¹. It is commonly observed in patients admitted to intensive care units and represents a significant challenge in critical care settings². The incidence of delirium is particularly high among patients receiving mechanical ventilation³.

ICU delirium is associated with adverse clinical outcomes including prolonged hospital stay, increased mortality, higher healthcare costs, and long-term cognitive dysfunction⁴. Despite its clinical significance, delirium often remains under-recognized and under-managed, especially in resource-limited settings and developing countries like India⁵.

Nurses play a major role in the prevention and management of ICU delirium because of their continuous bedside monitoring and direct patient care responsibilities¹. However, factors such as high workload, staff shortages, inadequate training, and lack of standardized delirium assessment protocols may limit effective implementation of preventive strategies⁶.

Critical care nurses may also experience moral distress, psychological burden, and workplace-related stress that can indirectly affect quality of patient care in ICU settings⁷.

MATERIAL AND METHODS:

A narrative review method was taken to synthesize existing evidence. Relevant studies published within the last 15 years were collected. Literature was searched using electronic databases such as PubMed, MEDLINE, and Google Scholar. Keywords used included “ICU delirium,” “critical care,” “nursing interventions,” and “ABCDEF bundle.” Inclusion criteria:

· Studies published in English.

· Studies involving adult ICU patients.

· Studies addressing delirium assessment or nursing protocols.

Exclusion Criteria:

· Pediatric population

· Non-ICU settings

· Studies without relevance to nursing care

· The selected studies were reviewed and findings were synthesized narratively.

RESULTS:

Recent literature indicates that ICU delirium is influenced by multiple patient-related, clinical, and environmental factors¹. Older age, cognitive impairment, severity of illness, and pre-existing neurological disorders significantly increase the risk of delirium⁸. Clinical conditions such as sepsis, hypoxia, electrolyte imbalance, and the use of sedatives—especially benzodiazepines—are strongly associated with ICU delirium⁹. Sedation-related delirium may be reversible in some critically ill patients following reduction of sedative exposure¹⁰.

Environmental factors including excessive noise, lack of natural light, sleep deprivation, and frequent interruptions further increase delirium risk¹¹. Prolonged mechanical ventilation and immobility are also recognized as major modifiable risk factors in ICU settings¹².

Studies suggest that early diagnosis and implementation of targeted nursing interventions significantly reduce the incidence, duration, and severity of ICU delirium¹³. Multicomponent non-pharmacological interventions have shown greater effectiveness compared to pharmacological approaches¹³. Structured approaches such as the ABCDEF bundle are associated with improved patient outcomes, shorter ICU stay, and reduced mortality¹⁴. Previous studies conducted in critical care settings have also identified caregiver stress, family needs, and nursing workload as important factors influencing overall patient care outcomes^15-16.

In the Indian healthcare context, barriers such as inadequate staffing, increased patient load, and lack of standardized delirium assessment tools continue to affect optimal delirium management⁶.

Table 1: Risk Factors of ICU Delirium

Category	Risk Factors
Patient-related	Advanced age, cognitive impairment
Clinical	Sepsis, hypoxia, metabolic imbalance
Treatment-related	Sedatives, mechanical ventilation
Environmental	Noise, sleep deprivation

ASSESSMENT AND EARLY DETECTION

Early identification of ICU delirium is essential for prompt intervention and improved patient outcomes¹. Nurses play a critical role in continuous monitoring and early identification because of their direct involvement in bedside care¹.

Standardized assessment tools are recommended for routine delirium screening. The Confusion Assessment Method for the ICU (CAM-ICU) is widely used because of its high validity and reliability¹⁷. It assesses four major features: acute onset or fluctuating course, inattention, altered level of consciousness, and disorganized thinking¹⁸. The Intensive Care Delirium Screening Checklist (ICDSC) is another validated screening tool commonly used in critical care settings¹⁹. Both CAM-ICU and ICDSC have demonstrated good sensitivity and specificity for delirium assessment in critically ill patients²⁰.

Adequate knowledge, clinical competency, and critical thinking abilities among nurses are essential for appropriate assessment and management of critically ill patients²¹.

Patients should be assessed routinely for delirium and findings should be documented accurately¹. Regular delirium assessment improves early recognition and facilitates timely intervention in ICU patients²². Early signs such as restlessness, altered sleep pattern, confusion, agitation, and reduced attention span should be recognized and reported promptly²³. Continuous monitoring allows timely implementation of preventive and therapeutic interventions, thereby reducing complications associated with delirium²⁴.

Nursing Interventions for Prevention:

Non-pharmacological nursing interventions are considered highly effective in preventing ICU delirium and are strongly supported by current evidence²⁵. Non-pharmacological interventions including orientation, sleep promotion, and environmental modification have shown beneficial effects in reducing delirium incidence²⁶. These interventions mainly focus on reducing modifiable risk factors and providing psychological support.

Evidence-based nursing care approaches and continuous staff education programs further improve the quality of care provided to critically ill patients²⁷.

Orientation and Cognitive Support:

Regular orientation regarding time, place, and person using clocks, calendars, and verbal reminders helps reduce confusion²⁵. Familiar objects and regular communication with patients further enhance orientation.

Sleep Promotion:

Sleep disturbance is a major contributing factor for delirium in critically ill patients. Nursing interventions such as reducing environmental noise, dimming lights at night, and clustering nursing activities help maintain circadian rhythm¹¹.

Early Mobilization:

Early mobilization including passive and active exercises reduces immobility-related complications and decreases delirium incidence¹². Regular educational interventions and skill-based training programs may improve nursing competency in critical care management^28-29.

Sensory Support:

Providing hearing aids, eyeglasses, and effective communication support reduces sensory deprivation and confusion⁸.

Hydration and Nutrition:

Maintaining adequate hydration and nutrition is essential because dehydration and metabolic imbalance increase delirium risk²⁴.

Family Engagement:

Encouraging family participation in patient care provides emotional support, reduces anxiety, and improves patient orientation³⁰. Addressing caregiver stress and family needs is also important for holistic ICU care and emotional support^15,31.

Collectively, these nursing interventions significantly reduce the incidence and severity of ICU delirium when implemented appropriately²⁵.

Abcdef Bundle Approach:

The ABCDEF bundle is an evidence-based framework developed to improve outcomes among critically ill patients and reduce ICU delirium³².

A – Assess, prevent, and manage pain: Adequate pain management reduces physiological stress and delirium risk³³.

B – Both spontaneous awakening and breathing trials: Reducing unnecessary sedation and ventilator dependence improves neurological recovery³⁴.

C – Choice of sedation: Avoidance of benzodiazepines and use of light sedation strategies reduce delirium incidence³⁵.

D – Delirium monitoring: Regular assessment using tools such as CAM-ICU ensures early detection¹⁷.

E – Early mobility and exercise: Promotes physical and cognitive recovery³⁶.

F – Family engagement and empowerment: Improves emotional well-being and patient orientation³⁰.

Implementation of the ABCDEF bundle has been associated with shorter ICU stay, reduced duration of delirium, and improved patient outcomes¹⁴.

Management of Icu Delirium:

Management of ICU delirium involves both non-pharmacological and pharmacological strategies, with emphasis on identifying and treating underlying causes³⁷. Spiritual and psychological support may contribute positively toward holistic nursing care among critically ill patients³⁸.

Non-Pharmacological Management:

First-line management includes preventive strategies such as reorientation, sleep promotion, mobilization, and environmental modification²⁵. Ensuring a calm and supportive environment helps reduce anxiety, agitation, and confusion.

Use of physical restraints should be minimized whenever possible, as they may increase delirium³⁹. Instead of restraint, patient safety should be managed through close observation and supportive care.

Pharmacological Management:

Pharmacological treatment is reserved for patients with severe agitation or those at risk of harming themselves or others⁴⁰. However, evidence regarding the effectiveness of haloperidol in reducing delirium duration remains inconsistent⁴¹. Antipsychotic drugs may be used safely, but their routine use is not strongly supported by evidence⁴². Some studies have also reported that low-dose nocturnal dexmedetomidine may help reduce the incidence of ICU delirium⁴³.

Nurses play a crucial role in:

· Monitoring drug effects and side effects

· Ensuring safe administration

· Evaluating patient response

Holistic Nursing Approach:

A holistic approach addressing physical, psychological, and environmental factors is necessary for effective ICU delirium management⁴⁴.

Table 2: Nursing Interventions and Outcomes

Intervention	Outcome
Orientation strategies	Improved cognitive status
Sleep promotion	Reduced delirium incidence
Early mobilization	Shorter ICU stay
Family involvement	Reduced anxiety and confusion

DISCUSSION:

ICU delirium is a common yet preventable complication among critically ill patients and is influenced by multiple patient-related and environmental factors²⁴. Early detection and timely nursing interventions are essential to reduce adverse clinical outcomes. Previous nursing studies have also emphasized the importance of nursing competency, family-centered care, emotional support, and holistic critical care approaches in improving patient outcomes^7,15,38.

Non-pharmacological interventions including orientation, sleep promotion, early mobilization, and family involvement are effective and feasible strategies in routine ICU practice²⁵. The ABCDEF bundle provides a structured multidisciplinary approach that improves patient outcomes and reduces delirium incidence³².

However, challenges such as staff shortages, heavy workload, inadequate training, and lack of standardized protocols may limit implementation, particularly in developing countries⁶. Pharmacological interventions should be used cautiously and only when clinically indicated⁴⁰.

Strengthening nursing education, improving delirium assessment practices, and implementing evidence-based care protocols are essential for improving delirium management in ICU settings^45-46.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 05.04.2026 Revised on 01.05.2026

Accepted on 21.05.2026 Published on 27.07.2026

Available online from August 01, 2026

Asian J. Nursing Education and Research. 2026;16(3):234-238.

DOI: 10.52711/2349-2996.2026.00047

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