Preventing Delirium in Older Adults on a Medical-Surgical Floor: An Evidence Appraisal of a Nurse-Led Sleep and Orientation Protocol
[Author Name]
College of Nursing and Health Care Professions, Grand Canyon University
NRS-445: Nursing Research and Evidence Based Practice
Topic 4 Assignment
[Instructor Name]
August 11, 2026
The setting and the figures below are a composite written as a model document. No employer, floor, colleague or patient is described.
The Practice Problem as It Appears on the Floor
The problem arrived as an impression before it arrived as a number. On a composite 32-bed medical-surgical floor, older patients who had been oriented and pleasant during the day were pulling at intravenous lines by two in the morning, asking for people who were not there, and being handed off in report as pleasantly confused. Over three consecutive night shifts I counted room entries for six patients between 2200 and 0600. The average was 14 entries per patient per night: routine vital signs at 0400, phlebotomy at 0500, a medication pass, and door alarms from the corridor. Sleep on that floor was never planned. It was whatever remained after everything else was scheduled.
The floor's own quality report turned the impression into a rate. In the 90 days ending May 31 the floor took 428 admissions, and 261 of those patients were 65 or older. Thirty-four of those 261 admissions had new confusion documented after the first day of the stay, or 13.0 percent, and their median length of stay was 6.8 days against 3.9 days for everyone else. Nine of the 34 required a bedside sitter, five had a soft limb restraint applied at least once, and four fell, one with a minor injury. None of those consequences were charted as delirium. They were charted as agitation, poor sleep, and a fall.
Naming the problem correctly changes what can be done about it. Confusion that begins after admission, fluctuates through the day and clears in some patients before discharge is a description of delirium, and delirium is an outcome the floor influences rather than an unavoidable feature of being old and unwell. The distinction matters at the bedside, because dementia arrives slowly and is not caused by a hospital stay, while this pattern arrived with the admission and moved by the hour. The floor had no routine screening for it, which is why the condition kept appearing under other labels in the record. Anything counted only after it becomes a sitter request is being counted too late to prevent.
That reasoning produced the question this paper answers. In hospitalized adults 65 and older on a medical-surgical floor, does a nurse-led multicomponent protocol covering sleep protection, orientation, sensory support and early mobility, compared with usual care, reduce the incidence of new delirium over a 90-day period? The question is deliberately narrow. It names the population by age and setting, the intervention by its parts rather than by a program name, and an outcome the floor already has a way of counting. A wider question, asking what improves outcomes in hospitalized older adults, would return thousands of results and support no decision by the end of the term.
Searching and Appraising the Evidence
The search ran in CINAHL Complete, MEDLINE through PubMed and the Cochrane Library, using delirium combined with prevention, multicomponent, nonpharmacological, sleep and hospitalized older adults. Filters held results to English language, adults 65 and older, and publication from 2014 onward, except for landmark reviews. Sources were ranked using the levels of evidence hierarchy that organizes systematic reviews and meta-analyses above single trials and expert opinion (Melnyk & Fineout-Overholt, 2023). Five sources survived screening because they addressed prevention in general hospital patients rather than intensive care or treatment after onset, and because each reported an outcome the floor could actually count.
The strongest evidence points the same way twice. A meta-analysis of multicomponent nonpharmacological interventions found the pooled odds of developing delirium to be roughly half those of usual care, along with a reduction in falls (Hshieh et al., 2015). A Cochrane review of prevention in hospitalized patients outside intensive care reached a consistent conclusion, judging that multicomponent interventions probably reduce delirium incidence compared with usual care while evidence for other outcomes remained less certain (Siddiqi et al., 2016). Two independent reviews agreeing on both direction and rough size is a stronger warrant than any single trial, and neither depended on a drug, a device or a budget line.
The remaining sources explain the mechanism and set the standard. Delirium develops when precipitating insults such as sleep loss, immobility and sensory deprivation act on a vulnerable brain, and a substantial share of hospital cases is considered preventable (Inouye et al., 2014). National guidance recommends identifying patients at risk on admission and addressing sleep, hydration, mobility, orientation and sensory aids as a package rather than singly (National Institute for Health and Care Excellence, 2023). The link to falls also matters for a medical-surgical floor, since confusion is a recognized fall risk factor in hospital fall prevention guidance (Agency for Healthcare Research and Quality, 2013), which is why four falls sit inside these 34 records.
Appraisal has to name limits as well as strength. Much of the underlying research was conducted on geriatric wards, in postoperative populations or in academic centers with trained volunteer programs, and staffing was rarely described in terms a floor nurse would recognize. Few reports isolate which component carries the effect, so the protocol cannot be trimmed on the evidence alone. No included report stratified outcomes by primary language, which matters where orientation depends on conversation. The trials that produced these results ran in settings with resources this floor does not have, and that gap is an argument about how to adapt the protocol rather than a reason to set it aside.
What the Evidence Would Change at the Bedside
The change is built from work the floor already does, rearranged. Every admitted patient 65 or older is screened once a shift with the 4AT, a four-item bedside tool that takes about two minutes and requires no special training. Night vital signs move from 0400 to 2300 and 0500 for clinically stable patients under a written order set, routine phlebotomy moves from 0500 to 0600, corridor lighting drops between 2300 and 0500, and earplugs and eye masks are offered at bedtime. Glasses and hearing aids brought from home are recorded on admission and placed on the patient each morning as a line on the shift checklist. Patients sit up for meals and walk three times daily unless there is an order against it.
One number decides whether it worked. The floor already counts new confusion after day one, so the measure is the number of patients 65 and older with newly documented delirium per 100 admissions in that age group, read monthly against the baseline of 13.0 and targeted at 9.0 or lower across 90 days. Two process measures sit under it: the share of eligible patients with a documented screen each shift, target 90 percent, and the share of protocol patients with no non-urgent room entry between midnight and 0400. Sitter hours and falls are tracked alongside, since a change that reduces documented confusion while sitter hours climb has not worked.
The obstacles are ordinary and predictable, and two of them do not belong to nursing. Draw times are set by the laboratory and vital sign timing sits in a provider order set, so both changes need a sponsor at the practice council rather than goodwill on nights. The third obstacle is a belief. Sleep on this floor is treated as a comfort item, and the evidence says it is a safety item, which is the single belief the change has to move. The honest limit of this appraisal is that it cannot say which component does the work, so the protocol goes in whole, is measured for one quarter, and is judged on the floor's own numbers rather than on the meta-analysis that suggested it.
References
Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html
Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. JAMA Internal Medicine, 175(4), 512-520.
Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922.
Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.
National Institute for Health and Care Excellence. (2023). Delirium: Prevention, diagnosis and management in hospital and long-term care (NICE guideline CG103). https://www.nice.org.uk/guidance/cg103
Siddiqi, N., Harrison, J. K., Clegg, A., Teale, E. A., Young, J., Taylor, J., & Simpkins, S. A. (2016). Interventions for preventing delirium in hospitalized non-ICU patients. Cochrane Database of Systematic Reviews, (3), Article CD005563. https://www.cochranelibrary.com
How this NRS 445 Topic 4 example is structured
In many sections this topic asks a working nurse to appraise the evidence behind one practice problem and say what it would change at the bedside; your classroom's instructions and the rubric decide the exact form, so read the assignment description before you use this NRS 445 Topic 4 example as a shape. The paper starts where the problem started, on the floor, because a question written before the observation tends to fit the literature rather than the practice. Local numbers come next and turn an impression into a rate with a denominator behind it. Appraisal follows, ordered by level of evidence and honest about what the trials never tested. The final section is the point of the paper: the change, the habit that will fight it, and the number that will show whether it worked.
NRS-445 Topic 4 questions, answered
What does NRS 445 Topic 4 usually ask for?
In many sections this topic asks you to take one practice problem you have seen, write a searchable question about it, then find and judge the evidence behind a possible change. Your classroom's instructions and the rubric decide the exact form and the required headings, so read the assignment description before treating any example as a template.
Can I write in first person in a nursing research paper?
Often yes, in the part where you describe what you observed in your own practice, since APA style permits first person for your own actions. Keep the appraisal itself in third person so the judgment rests on the evidence rather than on you. Check the rubric, because some sections still require third person throughout.
How do I keep my workplace out of the paper?
Describe the setting by type and size rather than by name, as a 32-bed medical-surgical floor in a community hospital. Use aggregate counts over a stated period instead of individual cases, leave out dates of care, roles that identify one colleague, and any detail that would let a reader place the building. Say in the paper that the setting is a composite.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Grand Canyon University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.