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Table 3 The Nursing Delirium Screening Scale (Nu-DESC)

From: Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial - The PINOCCHIO trial

  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