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?
Inattention
Did 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 Thinking
Was 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 5
1. Acute Onset plus
2. Fluctuating Course plus
3. Inattention plus
Either
4. 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
