Abstract Acute confusion is a major problem for a large number of orthopaedic patients, particularly older adults. Using a qualitative methodology, this exploratory study examined the experiences of orthopaedic nurses caring for acutely confused elderly patients. Analysis of interviews with ten orthopaedic nurses yielded a thematic framework that was used to code and categorize the data. Nurses determined acute confusion on the basis of observation of patients' behaviours, functioning and orientation as well as their knowledge of factors that predispose patients to the development of acute confusion. No standardized assessment tool or systematic assessment format was used. Once confusion was detected, nurses looked for possible causes. Interventions used by nurses included: constant surveillance, elimination of underlying causes, reorientation strategies, and caring human interactions. For those patients who were disruptive, three additional interventions: sitters, medications and restraints were used. Interviews revealed that acute confusion had far-reaching effects on nurses, patients, room-mates and families. Caring for acutely confused patients increased the nurses' workload, threatened their safety, affected their self-esteem and created mental conflicts.