Present if the actual RASS score is anything other than alert and calm (zero)

RASS anything other than zero

Feature 4: Disorganized thinking

Yes/No questions:

1) Will a stone float on water?

2) Are there fish in the sea?

3) Does one pound weigh more than two Pounds?

4) Can you use a hammer to pound a nail?

Errors are counted when the patient incorrectly answers a question.


Say to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient)

“Now do the same thing with the other hand” (Do not repeat number of fingers) *If the patient is unable to move both arms, for 2nd part of command ask patient to “Add one more finger”

An error is counted if patient is unable to complete the entire command.

Combined number of errors > 1