| Title |
Question(s) |
Points |
| Acute onset or fluctuation of mental status: |
- Is the patient different than his/her baseline mental status?
- Has the patient had any fluctuation in mental status in the last 24 hours as evidenced by fluctuation on a sedation/level of consciousness scale (such as RASS or GCS)?
|
- 0 for absent
- 1 for present
|
| Inattention |
Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter “A”, indicate by squeezing my hand.” Read letters from the following letter list in a normal tone 3 seconds apart. “SAVEAHAART” (Errors are counted when patient fails to squeeze on the letter “A” or when the patient squeezes on any letter other than “A.”) |
- 0 for absent (correct 8 or more)
- 1 for inattention (correct 4-7)
- 2 for severe inattention (correct 0-3)
|
| Altered Level of Consciousness |
Present if the actual Richmond Agitation-Sedation Scale Score is anything other than alert and calm (zero) |
- 0 for absent
- 1 for altered level (RASS:1, -1)
- 2 for severe altered (RASS:>1, <-1)
|
| Disorganized Thinking |
- Yes/No questions:
- Will a stone float on water?
- Are there fish in the sea?
- Does one pound weigh more than two pounds?
- Can you use a hammer to pound a nail?
- Errors are counted when the patient incorrectly answers a question
- Command: Say to patient “Hold up this many fingers” (Hold two Fingers in front of patient). “Now do the same with the other hand” (Do not repeat number of fingers)
- An error is counted if patient is unable to complete entire command
|
- 0 for absent (correct 4 or more)
- 1 for disorganized (correct 2-3)
- 2 for severe (correct 0-1)
|
