PATIENT’S NAME

MED. REC. #

DOB
Patient Identification
Date: ____/____/____
ASSESSMENT FOR DELIRIUM
7 a.m. – 3 p.m. 3 p.m. – 11 p.m.
This patient may be delirious if:
RASS Score Score =: Score =:
(Richmond Time: ___ ___ ___ ___ Time: ___ ___ ___ ___ 1.) RASS (Richmond Agitation and
MR 2140

Agitation and (24 hour) (24 hour) Sedation Scale) score is any
Sedation Scale) Initials: ____________ Initials: ____________ number except 0, 1 or -1
Is patient able to perform the Daily or
Test of Attention: Yes No
Time (24 hour): ___ ___ ___ ___ 2.) If patient cannot perform any Daily Test
Daily Test of Initials: ____________ of Attention.
Attention If Yes, please indicate test used:
Months of the year backwards If this is a NEW finding, this is considered an
Days of the week backwards “acute change in conscious state” and a
Counting backwards TRIGGER should be called.

RASS (Richmond Agitation and Sedation Scale) Test of Attention

4 = Combative = Overtly combative, violent, immediate danger to self
3 = Very agitated = Pulls or removes tube(s) or catheter(s); aggressive 1.) Ask patient to state the months of year backwards
2 = Agitated = Frequent non-purposeful movements (e.g., December, November, October…January). If
able, this becomes patient's Daily Test of Attention.
1 = Restless = Anxious but movements not aggressive, vigorous
0 = Alert and Calm If unable,
-1 = Drowsy = Not fully alert, but has sustained awakening
(eye opening / eye contact) to voice (greater than or equal to 10 seconds) 2.) Then ask to state days of week backwards (e.g.,
-2 = Light sedation = briefly awakens with eye contact to voice (less than 10 Sunday, Saturday, Friday…Monday). If able, this
seconds) becomes patient's Daily Test of Attention.
-3 = Moderate sedation = Movement or eye opening to voice (but no eye If unable,
contact)
-4 = Deep sedation = No response to voice, but movement or eye opening to 3.) Then, ask the patient to count from 10 to 1 (10, 9,
physical stimulation 8…1). If able, 10-1 becomes this patient's Daily
Test of Attention.
-5 = Unarousable = No response to voice or physical stimulation

MOBILITY PLAN / DELIRIUM PREVENTION STRATEGIES

Morning Tether Check: Does the patient still need:
R.N. discuss with M.D. the IVF: Yes No N/A
ongoing need for: Foley: Yes No N/A
1.) IVF Telemetry: Yes No N/A
2.) Foley
3.) Telemetry Time (24 hour): ___ ___ ___ ___ Initials: ________ Discussed with: _______________________ M.D.
7 a.m. – 3 p.m. 3 p.m. – 11 p.m. 11 p.m. – 7 a.m.
Yes Patient unable Yes Patient unable
Get patient out of bed to a
Time (24 hour): ___ ___ ___ ___ Time (24 hour): ___ ___ ___ ___
chair two times per day
Initials: ____________ Initials: ____________
Yes Patient unable Yes Patient unable
Ambulate patient in hallway
two times per day Time (24 hour): ___ ___ ___ ___ Time (24 hour): ___ ___ ___ ___
Initials: ____________ Initials: ____________
Turn off lights and television (or
change to the CARE channel),
Normalize sleep-wake cycle Minimize day-time napping
limit routine vital signs checks
and phlebotomy.
INITIAL & SIGNATURE KEY
Initials Signature & Credential Print Name Initials Signature & Credential Print Name

MR 2140 IP (Rev. 02/10)