Confusion Assessment Method for the ICU (CAM-ICU)

Confusion Assessment Method for the ICU (CAM-ICU) - Flowchart Confusion Assessment Method for the ICU (CAM-ICU) Confusion Assessment Method for the ICU (CAM-ICU)

«Flowchart»

1. Acute change or fluctuating course of mental status:

Is there an acute change from mental status baseline? OR
Has the patient's mental status fluctuated during the past 24 hours?

1. Acute change or fluctuating course of mental status:

Is there an acute change from mental status baseline? OR
Has the patient's mental status fluctuated during the past 24 hours?

1. Acute change or fluctuating course of mental status:

Acute change or fluctuating course of mental status:

Is there an acute change from mental status baseline? OR
Has the patient's mental status fluctuated during the past 24 hours?

Is there an acute change from mental status baseline? OR OR
Has the patient's mental status fluctuated during the past 24 hours?

YES

YES YES

NO NO

End

CAM-ICU negative
NO DELIRIUM

3. Altered level of consclousness: Current RASS level

3. Altered level of consclousness:

CAM-ICU negative
NO DELIRIUM

CAM-ICU positive
DELIRIUM PRESENT

RASS = zero

RASS = zero RASS = zero

RASS other than zero

RASS other than zero RASS other than zero

CAM-ICU negative
NO DELIRIUM

4. Disorganized thinking:

Command:

"Hold up this many fingers" (Hold up 2 fingers)
"Now do the same thing with the other hand" (Do not demonstrate) OR
"Add one more finger" (If patient unable to move both arms)

4. Disorganized thinking:

Command:

"Hold up this many fingers" (Hold up 2 fingers)
"Now do the same thing with the other hand" (Do not demonstrate) OR
"Add one more finger" (If patient unable to move both arms)

4. Disorganized thinking:

Will a stone float on water?
Are there fish in the sea?
Dose one pound weight more than two?
Can you use a hammer to pound a nail?

Command:

Command: Command:

"Hold up this many fingers" (Hold up 2 fingers)
"Now do the same thing with the other hand" (Do not demonstrate) OR
"Add one more finger" (If patient unable to move both arms)

"Hold up this many fingers" (Hold up 2 fingers)
"Now do the same thing with the other hand" (Do not demonstrate) OR OR OR
"Add one more finger" (If patient unable to move both arms)

>1 Error

>1 Error >1 Error

0-1 Error

0-1 Error 0-1 Error

2. In attention:

"Sequeeze my hand when I say the letter "A."
Read the following sequence of letters: SAVEAHAART
ERRORS: No sequeeze with 'A' & Sequeeze on letter other than 'A'
If unable to complete letters Pictures

2. In attention:

"Sequeeze my hand when I say the letter "A."
Read the following sequence of letters: SAVEAHAART
ERRORS: No sequeeze with 'A' & Sequeeze on letter other than 'A' "Sequeeze my hand when I say the letter "A."

ERRORS:
If unable to complete letters Pictures

>2 Errors

>2 Errors >2 Errors

0-2 Errors

0-2 Errors 0-2 Errors