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Click ‘Get Form’ to open the RASS and CAM-ICU worksheet in the editor.
Begin with the Sedation Assessment section. Carefully observe the patient and score their level of sedation using the Richmond Agitation and Sedation Scale (RASS). Record your observations based on the provided scoring criteria.
If the RASS score is above -4, proceed to the Delirium Assessment section. Evaluate each feature, starting with acute onset or fluctuating course, inattention, disorganized thinking, and altered level of consciousness.
For Feature 2, conduct the ASE Letters test. Record the score based on patient responses. If necessary, follow up with the ASE Pictures test for further assessment.
Complete all relevant fields in both sections before saving your work. Ensure that all scores are accurately recorded for effective patient evaluation.

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How do you document CAM-ICU results?

Documentation. The first step is to decide where the CAM-ICU assessment results will be documented. We recommend documenting the CAM-ICU in the hourly portion of the nursing flowsheet. Most institutions document the overall CAM-ICU score and not the individual features.

What is Rass and CAM-ICU assessment?

CAM-ICU: Confusion Assessment Method for the Intensive Care Unit; RASS: Richmond Agitation Sedation Scale; SAS: Sedation-Agitation Scale; GCS: Glasgow Coma Scale.

What is the CAM-ICU 7 score?

The three main instruments used in the ICU to measure delirium severity are the Confusion Assessment Method for the ICU (CAM-ICU)-7, which scores each original item from the original CAM-ICU on a scale from 0 to 7 (from 0 to 2: no delirium; 3 to 5: mild or moderate delirium; and 6 to 7: severe delirium);()the Delirium

What are the CAM-ICU criteria?

A positive CAM‐ICU will be based on the presence of two major criteria (acute or fluctuating onset and lack of attention) and at least one of the minor criteria (disorganized thinking or altered consciousness level) (Gonzalez 2003), following the instructions of the original authors (Ely 2016).

What is the difference between CAM-ICU and RASS?

The RASS has been evaluated as a standalone delirium assessment. Unlike the CAM, bCAM, CAM-ICU 3D-CAM, and 4AT, which requires the rater to perform cognitive testing on the patient, the RASS simply requires the rater to observe the patient during routine clinical care.