First of all, thank you to every one of you! Even those who weren't answering the question itself, you provided valid suggestions and food for thought.
To clarify some of the questions: This guy is in his mid 60's, has been on 40-60mg oxycodone IR q4h for years at home. That makes it tougher to avoid opiates because the opiate withdrawal itself could make him more confused and/or delirious, and I really don't need a miserable patient vomiting all over their sternal incision because they're basically withdrawing from heroin. There is definitely a huge case to be made for reducing use of opiates, benzos, anticholinergics when delirious. I think the rationale for the ativan was that this guy is absurdly strong and while he was a peach for me, he has been intermittently combative and come very close to injuring staff, so we have definitely been erring on the side of giving ativan when he starts to get angry or visually upset about something.
He did have restraints at times to prevent tube/line dislodgement but once he was extubated he would just scream constantly when restrained. He did have a sitter but it was discontinued because he would constantly talk (albeit pleasantly) and ask questions and it seemed like it was causing too much stimuli to have another person in the room with him constantly. Didn't help that she kept all the lights on, kept trying to re-orient him constantly even though it was absurdly ineffective, etc. I ended up being in the room twice as much when he had a sitter because she would call me in every time he touched his chest tube tubing or raised his voice, or she would let him have his call bell which he didn't understand how to use, then I would respond thinking it was her needing me, and she'd say 'oh yeah he's just going to push that button all night'. And I literally just couldn't even. The right sitter probably would've been a useful intervention, but the kind of sitters we were getting sent...
To address those of you who pointed at infection as a possible cause of this guy's delirium, yeah probably. He has been intermittently spiking fevers up to 101.9 for his entire postop course. We removed and replaced his lines to culture the tips, sent urine, sputum, and several sets of blood cultures over the course of several days. We sent his pleural fluid from an effusion for culture, his incisions don't look infected at all. Mild leukocytosis, WBC somewhere between 12 and 20. Infectious disease is consulted and basically want us to CT scan his chest/abdomen/pelvis to look for some other infectious source, but getting him to behave long enough to be scanned has been a tricky mistress.
Sodium was 155 when I picked him up. Gave IVF and encouraged PO fluids and was trending down by end of shift
ABG was normal
Glucose was right around 180-240
Wearing him out during the day to establish sleep/wake schedule is also an awesome suggestion, but made more difficult by the fact that this guy has basically not been out of bed in 2 weeks. Normally totally unheard of, but combo platter of hemodynamic instability, prolonged intubation and heavy sedation (every time we lightened sedation he would flip out, get agitated, breathe over the vent, not follow directions, etc. but the doses of sedation/pain meds needed to keep him calm were causing such respiratory distress that he actually got re-intubated a few times in his first few postop days). Anyway, he was already constantly moving around in bed, but now he's so deconditioned that it's going to be a long road to get him back to ambulatory. Agree he could probably be hoyered to a chair at least.
Normally I'm all about getting to the cause of the delirium so we can fix that, but in this case the equation simply has too many variables. Infection, prolonged ICU stay, sleep deprivation, lyte imbalances, high dose narcotics...well, they certainly complicate the clinical picture.
Now that we've discussed a bit, I have a follow up question.
When you go in the room to provide care, give meds, etc. and the delirious patient is coming at you with some ridiculous claim/version of reality, for example "Why won't you just give me the ice cream that's inside of that red box on the wall?", how exactly is one supposed to respond to that?
Things I've tried:
1. "That's a sharps bin. It's full of discarded needles. There is no ice cream in it." Then he got indignant and started accusing me of lying and saying he would get OOB and get the ice cream himself.
2. "We're all out of ice cream. Dietary will bring more in the morning" Then he started telling me which store I should go to to buy him some ice cream with the implication being that it wouldn't be out of the realm of possibility for me to stop caring for my assignment, leave the premises, find somewhere open at 3am, and buy him ice cream.
3. "You're diabetic and on an insulin drip. Your doctor says you can't have ice cream right now." Then he got indignant and started telling me that I was lying, the doctor said he should have ice cream.
4. Silence. Ignore the comment. He looks at me like I'm dumb and then starts accusing me of ignoring him.
5. "I'm going to the store to get you some ice cream, but you need to stay here in bed and leave all your lines, oxygen, etc. alone while I go. Every time you take something off I have to hightail it back here, and it will take much longer to go buy ice cream if you're not behaving." This worked until his goldfish memory reset itself, so 2 minutes max.
Basically I just feel like I can't win with patients like this. I feel like I have no idea what to say to them, reorientation doesn't work, they have no short term memory, no logic/sense. It seems like no matter what I say, I wind up exasperated, the patient winds up agitated or loud or attempting OOB. Nobody wins.
So, let's hear it. Who has things that they say to delirious patients that buy them some time to go care for other patients?