Understanding nurse responsibilities in managing postoperative agitation, delirium

Editor's Note

A recent article in AORN Journal underscores the need for vigilance and thorough documentation to manage postoperative mental status changes and prevent harm to both patients and staff.

As detailed in the article, cognitive disturbances such as delirium and agitation can complicate recovery after surgery. Delirium is characterized by impaired attention, awareness, and cognition, while agitation involves restlessness and distress. Both conditions often occur together, with one study finding that up to 60% of agitated patients also experienced postoperative delirium. Delirium also can be difficult to assess because its symptoms resemble lingering effects of anesthesia. Among pediatric patients, agitation after anesthesia occurs in about 30% of cases. Reported adult incidence rates vary widely—from 2.5 per 1,000 to nearly 19%—likely due to differing definitions and criteria.

Risk factors for agitation include obesity, preexisting psychiatric or cognitive conditions, and the presence of invasive devices such as urinary catheters or tracheal tubes. A retrospective analysis of electronic health records at the Mayo Clinic reviewed 56,275 adult surgical cases between May 2018 and December 2020. In total, 133 patients triggered behavioral emergency team responses—a 0.24% incidence. Of those, 21 involved physical aggression. Key predictors included male sex, longer surgical procedures, moderate or deep sedation, and being younger than 30 or older than 50. However, the strongest predictor was agitation in the PACU, associated with an odds ratio of 8.47 for subsequent behavioral team activation.

The article emphasizes that PACU nurses should communicate observations of agitation during handoff to receiving units to enable heightened vigilance. Unpredictable behavior can escalate quickly, and early recognition is key to prevention. A recent California state law requiring healthcare workers to report violent incidents identified 37,561 incidents from 418 hospitals between 2017 and 2021. Of these, 95% were patient-perpetrated, and 11,816 resulted in physical injury.

To mitigate risk, the article advises ruling out hypoxemia first, maintaining a calm demeanor, using a soft tone, and avoiding confrontation. Validating emotions and reorienting patients can help de-escalate tension. If aggression seems imminent, staff should call for help immediately.

The authors stress that even nonviolent disturbances can erode healthcare workers’ well-being. Institutions should ensure clear violence-prevention protocols are in place and that frontline staff know how to access them.