NEECHAM Confusion Scale

The NEECHAM Confusion Scale was developed by nurses in order to be able to assess patients based on observation in the course of giving care to patients. The scale consists of components representing cognitive function: information processing and performance; and vital function items. It combines nursing assessment and brief interactions with patients, and the scale takes 10 minutes to complete. It has good validity and reliability.

Scoring to be added

See Neelon NV, Champagne, M.T., Carlson, J.R., Funk, S.G. 1996. The NEECHAM Confusion Scale: construction, validity and clinical testing. Nursing Research 45: 324–30

status:published
version:1.0
source:
tags: mental health, delirium

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Level I - Processing
 
Attention: (Attention-Alertness-Responsiveness)
 
Full attentiveness/alertness [4]
Short or hyper attention/alertness [3]
Attention/alertness inconsistent or inappropriate [2]
Attention/alertness disturbed [1]
Arousal/responsiveness depressed [0]
Command: (Recognition-Interpretation-Action)
 
Able to follow a complex command [5]
Slowed complex command response [4]
Able to follow a single command [3]
Unable to follow direct command [2]
Unable to follow visual guided command [1]
Hypoactive, lethargic [0]
Orientation: (Orientation, Short-Term Memory, Thought/Speech Content)
 
Oriented to time, place, and person [5]
Oriented to person to place [4]
Orientation Inconsistent [3]
Disoriented and memory/recall disturbed [2]
Disoriented, disturbed recognition [1]
Processing of stimuli depressed [0]
Level 2- Behavior
 
Appearance
 
Controls posture, maintains appearance, hygiene [2]
Either posture or appearance disturbed [1]
Both posture and appearance abnormal [0]
Motor
 
Normal motor behavior [4]
Motor behavior slowed or hyperactive [3]
Motor movement disturbed [2]
Inappropriate, disruptive movements [1]
Motor movement depressed [0]
Verbal
 
Initiates speech appropriately [4]
Limited speech initiation [3]
Inappropriate speech [2]
Speech/sound disturbed [1]
Abnormal sounds [0]
Level 3- Physiologic Control
 
Physiological Measurements
 
Temperature
 
Systolic BP
 
Diastolic BP
 
Heart rate
 
Heart rate
 
regular
irregular
Respirations
 
O2 saturation
 
Periods of apnea/hypopnea present?
 
yes     no
Oxygen therapy prescribed?
 
no [0]
yes, but not on [1]
yes, on now [2]
Vital Function Stability
 
BP, HR, TEMP, RESPIRATION within normal range with regular pulse [2]
Any one of the above in abnormal range [1]
Two or more in abnormal range [0]
Oxygen Saturation Stability
 
O2 sat in normal range (93 or above) [2]
O2 sat 90 to 92 or is receiving oxygen [1]
O2 sat below 90 [0]
Urinary Continence Control
 
Maintains bladder control [2]
Incontinent of urine in last 24 hours or has condom cath [1]
Incontinent now or has indwelling or intermittent catheter or is anuric [0]

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