Case 24 of 40
Treat dehydration carefully when delirium occurs with kidney injury and heart failure
Example case for staff education
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Read the case transcript
Page 1
Panel 1: Day 1
Several days of diarrhoea and poor intake precede confusion.
Ellis: She usually manages her medicines herself.
Panel 2: Day 1
She has dehydration, kidney injury and known heart failure.
Ward doctor Amira: We need fluids with frequent reassessment.
Panel 3: Day 1
Treatment begins with a plan to review the response.
Nurse Tom: I will report any change in breathing straight away.
Panel 4: Day 2
A gabapentinoid and other medicines need review during kidney injury.
Pharmacist Samir: What has she actually taken over the last few days?
Panel 5: Day 2
Medication is adjusted while pain and alertness are monitored.
Ward doctor Amira: We will check whether she becomes more alert and remains comfortable.
Panel 6: Day 3
Improving alertness does not establish recovery of attention.
June: Have we already had breakfast?
Panel 7: Day 3
A new respiratory change prompts immediate assessment.
Nurse Tom: Her breathing has changed since this morning.
Panel 8: Day 3
Fluid overload is identified; the treatment plan changes.
Ward doctor Amira: Pause the fluids and reassess the balance now.
Panel 9: Day 4
Breathing improves as congestion is treated.
June: It is easier to breathe sitting here.
Page 2
Panel 10: Day 5
Kidney function and breathing are improving; delirium persists.
Ward doctor Amira: We still need to assess pain, intake, bowels and medicines.
Panel 11: Day 5
Constipation and discomfort are addressed.
Nurse Tom: Tell me if that still hurts afterwards.
Panel 12: Day 6
She cannot yet organise eating and drinking alone.
Ellis: She forgets what she was doing halfway through.
Panel 13: Day 7
Activity is paced to breathlessness, fatigue and attention.
Physiotherapist Lin: We can stop here and try again later.
Panel 14: Day 9
Clearer periods become longer but remain inconsistent.
June: I can listen better when there is only one person talking.
Panel 15: Day 10
Stable blood results do not make medicine management safe.
Ward doctor Amira: Someone will need to supervise the tablets for now.
Panel 16: Week 2
The plan includes fluid advice and early clinical follow-up.
Nurse Tom: The community team will contact you tomorrow.
Panel 17: Week 3
Breathing remains stable; attention is improving slowly.
Ward doctor Amira: Let us check how meals and medicines are actually going.
Panel 18: Week 3
June still needs help with tasks she previously managed alone.
June: I can do this part if you stay with me.
Sources
- [T02] MacLullich AMJ. Persistent delirium. CHG Singapore teaching presentation, 2025. Teaching slides.
- [P43] Dharmarajan K, Swami S, Gou RY, Jones RN, Inouye SK. Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality. Journal of the American Geriatrics Society. 2017;65:1026–1033.
- [G01] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
Commentary
June is dehydrated, but she also has conditions that make giving too much fluid dangerous. Staff examine her repeatedly and check her response to treatment. Improving kidney function does not replace assessment of breathing, circulation, intake and thinking.
June takes a gabapentinoid, which may have greater effects when kidney function is impaired. Several factors may contribute to her drowsiness. The team adjusts treatment and monitors her response without attributing all her symptoms to that medicine. Pain relief continues. Later breathlessness requires assessment for fluid overload and must not be attributed to anxiety or delirium without assessment.
This teaching example describes several problems occurring together. Guidance recommends identifying and treating combinations of causes [G01]. The sources do not describe June or establish the effects of her individual treatment changes. Consider her medicines, kidney function and fluid balance together.
By the second week, her physical measurements are stable, but she still has difficulty paying attention and organising tasks. Rehabilitation and discharge support need to account for these difficulties. Identify observations that would justify changing treatment or assessing a new deterioration. June improves but still needs help with medicines and meals [P43].