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.

Command:

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 2^nd 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