ICU Assessment Scales AH4 WK1

CAM-ICU Definition

Confusion Assessment Method

standardized tool used to assess and detect delirium in critically ill patients, including those who are mechanically ventilated. It evaluates acute changes in mental status, inattention, altered level of consciousness, and disorganized thinking to support early identification and management of delirium.

CAM-ICU Feature 1 (Alteration/Fluctuation of Mental Status) Grading

• Is the patient’s mental status different than his/her baseline?

OR

• Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation scale (eg, RASS, Glasgow Coma Scale [GCS]), or previous delirium assessment?

If Yes for either question mark as Present

CAM-ICU Feature 2 (Inattention) Grading

Tell the patient “I am going to read to you a series of 10 letters. Whenever you hear the letter ‘A,’ squeeze my hand”

Examples of what to say - SAVEAHAART, CASABLANCA, or ABADBADAAY.

Count errors (each time patient fails to squeeze on the letter “A” and squeezes on a letter other than “A”)

If more than 2 errors mark as present

CAM-ICU Feature 3 (Altered LOC) Grading

• Present if RASS is anything other than Alert and Calm (anything other than 0)

OR

• Present if SAS is anything other than Calm (anything other than 4)

CAM-ICU Feature 4 (Disorganized Thinking) Grading

Yes/No Questions: Ask the patient to respond:
1. Will a stone float on water?
2. Are there fish in the sea?
3. Does 1 pound weigh more than 2 pounds?
4. Can you use a hammer to pound a nail?
Count errors (each time patient answers incorrectly).

Commands Ask the patient to follow instructions:

a) “Hold up this many fingers” (Hold up two fingers in front of the patient)

b) “Now do the same thing on the other hand” (Do NOT demonstrate for the patient)

• If unable to move both arms, for part “b” of command ask patient to “Hold up one more finger.”

Count Errors

If combined errors are greater than 1 mark as present

CAM-ICU Score interpretation

If Features 1 and 2 are both present AND either features of 3 OR 4 are present = positive, delirium is present

(CPOT) Definition

Critical Care Pain Observation Tool

A validated assessment tool used to evaluate pain in critically ill patients who are unable to self-report.

It measures behavioral indicators such as facial expression, body movements, muscle tension, and compliance with the ventilator or vocalization to guide pain management in ICU settings

CPOT Facial Expressions (Grading)

Relaxed/Neutral - Score = 1 - No muscle tension observed

Tense - Score = 1 - Presence of frowning, brow lowering, orbit tightening, and levator contraction or any other change (eye opening or tearing during nociceptive procedures)

Grimacing - Score = 2 - All previous facial movements plus eyelid tightly closed (pt may present with mouth open or biting ET tube)

CPOT Body Movements (Grading)

Absence of movements or normal position - Score = 0 - Does not move at all/ movements not aimed at site or not made for the purpose of protection.

Protection - Score = 1 - Slow, cautious moments, touching or rubbing site, seeking attention through movements.

Restlessness - Score = 2 - Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking staff, trying to climb out of bed

CPOT Compliance with Ventilator in Intubated Pts (Grading)

Tolerating - Score 0 - Alarms not activated, Easy ventilation

Coughing but tolerating - Score = 1 - Coughing, alarms may be activated but stop spontaneously

Fighting Ventilator - Score = 2 - Asynchrony, blocking ventilation, alarms activated frequently

CPOT Vocalization in Extubated Pts (Grading)

Talking in normal Tone/ No Sound - Score = 0

Sighing/Moaning = 1

Crying out/Sobbing = 2

CPOT Muscle Tension (Grading)

Relaxed - = 0 - No resistance to passive movements

Tense, rigid - = 1 - Resistance to passive movements

Very Tense, Rigid = Strong Resistance to passive movements, incapacity to complete them

CPOT Interpretation

Target Score: 0-1

Score of 0-2 - minimal/ no pain present, continue to observe and assess

3-8 mod/ severe pain, consider further sedation/analgesia

RASS Definition

The Richmond Agitation-Sedation Scale

standardized tool used to assess a patient’s level of sedation and agitation in critical care settings. It ranges from combative (+4) to unarousable (−5) and helps guide sedation management, ensuring patients are maintained at an appropriate and safe level of alertness.

RASS Grading

• +4 | Combative: Overly combative or violent; presents an immediate danger to staff.

• +3 | Very Agitated: Pulls or removes tubes/catheters; exhibits aggressive behavior toward staff.

• +2 | Agitated: Displays frequent non-purposeful movement.

• +1 | Restless: Anxious or apprehensive, but movements are not aggressive or vigorous.

• 0 | Alert and Calm: Spontaneously alert and calm.

• -1 | Drowsy: Not fully alert, but sustains awakening and eye contact to voice for >10 seconds.

• -2 | Light Sedation: Briefly awakens and makes eye contact to voice for <10 seconds.

• -3 | Moderate Sedation: Any movement to voice, but no eye contact.

• -4 | Deep Sedation: No response to voice, but exhibits movement in response to physical stimulation.

• -5 | Unarousable: Completely unresponsive to verbal or physical stimulation.

RASS Procedure

• Step 1: Observe patient.

  • Patient is alert, restless or agitated. 0 to +4

• Step 2: If not alert, state patient's name and say to open eyes and look at speaker.

  • Patient awakens with sustained eye opening and eye contact. - 1

  • Patient awakens with eye opening and eye contact but not sustained. - 2

  • Patient has any movement in response to voice but no eye contact. - 3

• Step 3: If patient does not respond to voice, physically stimulate patient by shaking shoulder and/or rubbing sternum*:

  • Patient has any movement to physical stimulation. - 4

  • Patient has no response to any stimulation. - 5