AACN Essentials of Critical Care Nursing Practice Test

Screening delirium in patients who cannot speak or communicate effectively is best done with CAM-ICU. This tool is specifically designed for ICU patients who are nonverbal or sedated and can be applied at the bedside to rapidly identify delirium. CAM-ICU uses a simple algorithm based on four features: acute change or fluctuating course, inattention, altered level of consciousness, and disorganized thinking. Delirium is present when there is an acute change or fluctuation and inattention, plus either disorganized thinking or an altered level of consciousness.

Other tools focus on different targets: the Glasgow Coma Scale measures level of consciousness and can’t distinguish delirium from coma or other cognitive states; the MMSE assesses general cognitive function but isn’t practical or validated for ICU delirium screening in nonverbal patients; and APACHE II gauges illness severity, not delirium.