Confusion Assessment Method (CAM)

Purpose:•Provide initial and ongoing screening of patients for identification of signs and symptoms of delirium. •Initiate interventions based on CAM screening and symptoms presented.

When is CAM tool used?

All patients age 65 and older◦Q shift

Any patient with onset of acute confusion.

CAM Screening Components:CAM screens for the presence of four

clinical features of delirium (does not identify severity)

• Acute onset and Fluctuating Course

• Inattention

• Disorganized Thinking

• Altered Level of Consciousness

Acute Onset and Fluctuating Course

Is there evidence of an acute change in mental status?◦Worsening memory, language

impairments, disorientation, perceptual disturbances – usually over hours to days? May require information from family member,

caretaker, or nurse who is familiar with patient’s baseline.

Did the abnormal behavior come and go or increase or decrease in severity?

InattentionDid patient have difficulty focusing

attention, for example being easily distractible, or having difficulty keeping track of what was being said?

Symptoms of Inattention:◦ Must frequently repeat questions because

attention wanders- not due to hearing loss.◦ Unable to gain pt attention or make

prolonged eye contact.◦ Pt may look at you for a moment and stare

off into space; does not respond to your questions.

Disorganized ThinkingWas the patient’s thinking disorganized

or incoherent, such as rambling or irrelevant conversations, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Example: You ask patient if they are having any pain and

the patient states that he needs to go to the mailbox to pick up his mail.

Altered Level of Consciousness: Alert (normal) Vigilant (hyperalert) Lethargic (drowsy, easily

aroused) Stupor (difficult to arouse) Coma (unarousable)

A positive screen for Delirium includes:Scoring: 1 + 2 + 3 plus either 4

and/or 51. Acute Onset plus2. Fluctuating Course plus 3. Inattention plus Either4. Disorganizing Thinking

and/or 5. Altered Level of

consciousness

Interventions:Interventions for patients who have delirium are very simple, basic, geriatric nursing practices.

May be used proactively for any patients who are at risk for becoming confused.

CAM Interventions:

Activity:-Chair for meals -Dangle legs -Ambulate 3x day-ROM 2X/Day-D/C tethers, -Avoid restraints-Tasks

Sleep Enhancement

-adhere to schedule-no wake at night -avoid day naps -reduce noise -avoid sedatives-Warm milk -no caffeine-relaxing music -message hand/foot-essentials oils

CAM Interventions:

Cognitive impairment/disorientation:◦Keep day/night orientation (window

shades open)◦Clock/calendar in room◦Reorient often to person/place/time◦Therapeutic

activities/communication◦Facilitate visits from friends/family◦Consistent staff members◦Avoid transferring rooms/units

CAM Interventions:

Visual and Hearing: Glasses worn or other visual aid Hearing aid or pocket talker Specialty phone

PATIENT AND FAMILY EDUCATION DOCUMENT Document Found InfoNet:Krames on Demand: Custom Documents

Delirium Patient and Family Education

Questions, contact:Nora McPherson, RN, GCNS-BC Jill Tusing MS, RN-BC