Table 1 Nursing delirium screening scale

1 Disorientation

0

1

2

Verbal or behavioral manifestation of not being oriented to time or place or misperceiving persons in the environment

2 Inappropriate behavior

0

1

2

Behavior inappropriate to place and/or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when contraindicated, and the like

3 Inappropriate communication

0

1

2

Communication inappropriate to place and/or for the person; e.g., in-coherence, non-communicativeness, nonsensical or unintelligible speech

4 Illusions/Hallucinations

0

1

2

Seeing or hearing things that do not exist; distortions of visual objects

5 Psychomotor retardation

0

1

2

Delayed responsiveness, few or no spontaneous actions/words; e.g., when the patient is prodded, the reaction is deferred and/or the patient is unarousable