Table 3 The Nursing Delirium Screening Scale (Nu-DESC)
| Symptoms |
Symptoms Rating 0 = no symptoms 1 = mild symptoms 2 = pronounced symptoms | |
|---|---|---|
| 1 |
Disorientation
Verbal or behavioural manifestation of not being oriented to time or place or misperceiving persons in the environment. | |
| 2 |
Inappropriate behaviour
Behaviour inappropriate to place or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when that is contraindicated, and the like. | |
| 3 |
Inappropriate communication
Communication inappropriate to place or for the person; e.g., incoherence, noncommunicativeness, nonsensical or unintelligible speech. | |
| 4 |
Illusions/Hallucinations
Seeing or hearing things that are not there; distortions of visual objects. | |
| 5 |
Psychomotor retardation
Delayed responsiveness, few or no spontaneous actions/words; e.g., when the patient is prodded, reaction is deferred or the patient is unarousable | |
| Total Score | ||
| Delirium | ≥ 2 |