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Table 1 Nursing delirium screening scale [16]

From: Postoperative delirium assessed by post anesthesia care unit staff utilizing the Nursing Delirium Screening Scale: a prospective observational study of 1000 patients in a single Swiss institution

Symptom

Symptom rating

1 Disorientation

Verbal or behavioral manifestation of not being oriented to time or place or misperceiving persons in the environment

2 Inappropriate behavior

Behavior inappropriate to place and/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 and/or for the person; e.g., in-coherence, non-communicativeness, 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 and/or the patient is unarousable.