Delirium, Agitation, and Behavioral Emergencies on the CCRN (PADIS 2018 and 2025)

Behavioral and psychosocial items in the 2025 CCRN test plan

The Adult CCRN test plan for exams on and after November 12, 2025, groups Musculoskeletal, Neurological, and Behavioral/Psychosocial problems into one category worth 18% of the exam. Its behavioral list has ten problems: agitation, aggression, delirium, non-adherence, mood disorders, post-intensive care syndrome (PICS), PTSD, self-harm, substance use disorder, and suicidal ideation. Delirium used to sit under Neurological and PICS under Multisystem; both moved to this list in 2025, as the test plan changes guide explains.

The testable nursing actions include behavioral assessment tools for delirium and alcohol withdrawal, and de-escalation. Expect stems that ask for the best plan, not just the name of the problem.

What PADIS suggests for sedation and delirium, and what it declines to recommend

The Society of Critical Care Medicine published the PADIS guidelines in 2018 and a focused update in 2025. Almost every statement below is conditional ("we suggest"), which means it should be tailored to the patient.

Two 2018 statements explain why benzodiazepine infusions keep showing up in delirium stems. PADIS lists benzodiazepine use, along with blood transfusion, as a modifiable risk factor with strong evidence for delirium. It also says critically ill adults should be assessed regularly for delirium with a valid tool.

The AACN blog summary of the 2025 update (September 29, 2025) adds a practical caution: dexmedetomidine can increase the risk of bradycardia, and other options should be considered for patients who need deep sedation or are at high risk of bradycardia.

Nonpharmacologic delirium actions a nurse controls

PADIS 2018 describes the multicomponent strategy in terms that map directly onto bedside work:

• Orientation and thinking: reorient the patient, offer cognitive stimulation, and keep a clock in view.
• Sleep: reduce light and noise at night.
• Wakefulness: reduce sedation where the plan allows.
• Movement: start early rehabilitation or mobilization when the patient is stable.
• Senses: make sure the patient has hearing aids and glasses in use.

AACN's Practice Alerts include "Assessment and Management of Delirium Across the Life Span" and "Promoting Sleep in Acute and Critically Ill Adults" (published June 1, 2026), and the AACN blog points to the ABCDEF bundle as a way to put PADIS into daily routines.

Here is an original example. A ventilated man on a fentanyl infusion screens CAM-ICU positive at 02:00 and is picking at his lines. The room lights are on, the television is running, his glasses are in the bedside drawer, and he has not been out of bed in four days. A strong exam answer assesses his pain first with a behavioral tool, then fixes what the nurse controls: lights and noise down, glasses and hearing aids in, reorientation, a mobility plan for the morning, and a conversation with the team about whether his sedation can be lightened. Restraints as the first move are a weak answer: PADIS 2018 notes they are widely used without evidence of benefit and with safety concerns, including unplanned extubation and greater agitation.

The free 20-question CCRN (Adult) set includes a delirium item about a patient on a continuous benzodiazepine infusion. After the example above, try the benzodiazepine-infusion delirium item → and read why the other three plans fall short of PADIS.

Alcohol withdrawal in the ICU: timeline and priorities

The MSD Manual's chapter on alcohol toxicity and withdrawal (full review June 2025) describes withdrawal as a continuum. Its timeline is the part most often tested:

MSD says delirium tremens may be fatal and must be treated promptly, that severe withdrawal and delirium tremens are managed in an ICU, and that benzodiazepines are the mainstay of therapy. It recommends thiamine to prevent Wernicke encephalopathy and points to a severity tool, the CIWA-Ar scale. The exam pattern is a patient admitted for something else who becomes tremulous, sweaty, tachycardic, and confused on day two or three. Recognize the timeline and report early, while assessing other causes of delirium. CIWA-Ar relies on patient-reported symptoms and is unsuitable for a delirious or noncommunicative patient. ASAM recommends structured ICU assessments such as CAM-ICU, RASS, or MINDS for alcohol withdrawal delirium, selected under the unit's protocol.

Verbal de-escalation before restraint or sedation

The American Association for Emergency Psychiatry's Project BETA consensus statement on verbal de-escalation (Western Journal of Emergency Medicine, 2012) describes three steps: engage the patient verbally, build a collaborative relationship, and then talk the patient down from the agitated state. Its ten domains can be grouped into three things the nurse does:

• Make the space safe: keep a respectful distance, avoid provoking postures or tones, and establish verbal contact early.
• Communicate briefly and listen: use short sentences, find out what the patient wants and feels, and agree where you can, or agree to disagree.
• Set limits and offer choices: state clear, respectful limits, offer real choices and some optimism, and debrief the patient and staff afterward.

On the exam, a calm verbal approach usually comes before medication or restraint unless the stem describes an immediate danger.

Suicidal ideation and self-harm on a critical care unit

The National Institute of Mental Health's Ask Suicide-Screening Questions (ASQ) toolkit includes materials for inpatient medical and surgical units. Its information sheet describes four screening questions; a "yes" to any of them, or a refusal to answer, is a positive screen, and a fifth question checks for current thoughts of suicide.

• Acute positive (current thoughts): the patient needs a STAT safety or full mental health evaluation, cannot leave until evaluated, stays in sight, and dangerous objects are removed from the room. The responsible clinician is alerted.
• Non-acute positive: the patient needs a brief suicide safety assessment to decide whether a full evaluation is needed, and also cannot leave until evaluated for safety.

The nurse's role in these items is to screen, keep the patient safe, and escalate under the hospital's protocol, not to complete the psychiatric evaluation.

PICS and what delirium does and does not predict

PADIS 2018 reports that a positive delirium screen is strongly associated with cognitive impairment at 3 and 12 months after ICU discharge. It also reports that delirium has consistently not been associated with PTSD or post-ICU distress. Both PICS and PTSD are now on the behavioral list, so keep these two findings apart when a stem links delirium to life after the ICU. The neuro and musculoskeletal review covers the rest of the category, and the ethics and advocacy guide covers family involvement and speaking up for the patient.