Screening for Delirium, Dementia and Depression in Older Adults

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Screening for Delirium, Dementia and Depression in Older AdultsLEVEL 3 – PHYSIOLOGIC CONTROLPHYSIOLOGIC MEASUREMENTSRecorded ValuesNormal RangesTemperature (36-37ºC) Periods of apnea/hyponea?1 = yes, 2 = noSystolic BP (SBP) (100-160) Oxygen therapy prescribed?Diastolic BP (DBP) (50-90 ) 0 = no, 1 = yes, but not on,2 = yes, on now70O2 saturation(93 or above)Respiration (14-22)(count 1 minute)Heart Rate (HR) (60-100)Regular/Irregular(Circle one)VITAL FUNCTION STABILITYCount abnormal SBP and/or DBP as one value; count abnormal and/or irregular HR as one;count apnea and/or abnormal respiration as one; and abnormal temperature as one.2 BP, HR, TEMP, RESPIRATION within normal range with regular pulse.1 Any one of the above in abnormal range.0 Two or more in abnormal range.OXYGEN SATURATION STABILITY2 O2 sat in normal range (93 or above)1 O2 sat 90 to 92 or is receiving oxygen0 O2 below 90
Nursing Best Practice GuidelineURINARY CONTINENCE CONTROL2 Maintains bladder control.1 Incontinent of urine in last 24 hrs. or has condom catheter.0 Incontinent now or has indwelling or intermittent catheter or is anuric.SCORINGTotal ScoreIndicatesLEVEL 1 Score 0-19 Moderate to severeProcessing (0-14 points)confusion71LEVEL 2 Score 20-24 Mild or early developmentBehaviour (0 -10 points)of confusionLEVEL 3 Score 25-26 “Not confused,” but at highPhysiological Control (0-6 points)risk for confusion27-30 “Not confused,” or normalfunctionTOTAL NEECHAM (0-30 points)Reprinted with permission of Dr. Virginia Neelon.
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Screening for Delirium, Dementia and Depression in Older Adults

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