Date/shift
Name:
Hospital number:
Ward:
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
N
PM
AM
Distress
1 2 3 4 5
Agitation/Act.
1 2 3 4 5
Cognitive
1 2 3 4 5
Apathy/withdr.
1 2 3 4 5
Conflict
1 2 3 4 5
5
6
7
8
9
TOTAL
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
NURSING OBSERVED ILLNESS
INTENSITY SCALE
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Agitation and activity
Apathy and withdrawal
Calm and relaxed all the time, no excessive movement or
activity
1
Out in the day room or other public ward areas, interacting
with others at a normal level and engaging in ward activities
1
Signs of restlessness from time to time (e.g. fidgeting,
swinging or arms and legs, frowning, increased facial
expressiveness occasional gesticulations)
2
Present in the main public ward areas, but does not initiate
social interaction or activities
2
Brief episodes of pacing, of gross body movement or activity,
with other signs of restlessness at other times, possibly with
increased talking
3
Although present in the main ward areas, does not converse
with others except in monosyllables, and passively avoids
social interaction unless specifically required or encouraged
3
Extended signs of restlessness, overactivity, agitation, tension
or irritability, unable to concentrate, unable to keep still or
remain seated half of the time
4
Spends half the time isolating self around bed space or other
areas where chances for interaction are minimised. When
approached gives only brief responses.
4
Patient agitated or overactive for nearly the whole time,
constantly on the go, unable to keep still, and/or tense,
irritable and hyper responsive to noises or to the actions of
others, and/or interfering with others
5
Isolates self at every opportunity, avoids interaction with
others, spends virtually the whole time keeping solitary,
and/or is close to mute
5
Psychological Distress
Conflict (score the highest that applies)
1
Patient is fully compliant with ward rules and accepts all
treatment and engages in therapeutic activities
1
Some discomfort due to infrequent worries, pessimism,
suspicion, fear about present and/or future, or other
unpleasant emotions
2
Patient fails to comply with ward rules (e.g. re smoking),
and/or refuses to see workers, and/or to engage in activities,
and/or wash, and/or get up and out of bed when asked, or
refuses to go to bed, and/or is abusive
2
Apprehensive, suspicious, unhappy, irritable or dysphoric for
most of the day but without impairment in functioning
3
Patient refuses to accept treatment (e.g. medication), or is
suspected (or known) to have consumed illegal drugs or
alcohol
3
Some areas of daily functioning are disturbed by anxiety,
guilt, helplessness, depression, suspicion, irritability; cries or
expresses distress in other ways
4
Patient attempts to or succeeds in absconding
4
Many areas of daily functioning are disrupted by constant
worries, irritability, guilt, inappropriate affect, paranoia,
distress, sadness, helplessness or other dysphoria
5
Patient is aggressive to objects or others, or attempts or
succeeds to harm self or others
5
Calm and relaxed throughout the shift
Cognitive accessibility
Speech content and behaviour normal
1
Patient talks about delusions when specifically asked, or
reports hearing voices when asked, or shows some thought
disorder during conversation
2
Patient seeks out others to talk about delusional material, or
shows obvious signs of experiencing episodes of
hallucinations, or conversation is hard to understand due to
thought disorder or confusion
Patient's conversation dominated by delusional material, or is
preoccupied with hallucinations or affected by thought
disorder or confusion to the degree that conversation is
difficult, but not impossible
Patient totally obsessed with delusional material and/or
apparently hallucinating nearly constantly, and/or impossible
to communicate with at all due to cognitive disorganisation
3
4
5