Download Version 11 - Data Collection Tool

Date: _____________________
Ward: ___________________
Name & Grade of Data Collector: _____________________________________________________
Patient Age:
Sex:
Presenting Complaint:
Admission Diagnosis:
Date & Time of Admission:
Was an MSQ test performed?
Was delirium documented?
□ Yes
□ Yes
□ No
□ No
/
/
:
Score ______
□ RULED OUT
Is there any evidence of recent cognitive change?
□ Normal □ Agitation □ Drowsiness □ Confusion □ Inattention
□ Other descriptors e.g. “off the legs” etc. ____________________________
COMMON PRECIPITATING FACTORS IN DELIRIUM
FACTORS THAT INCREASE RISK OF DEVELOPING
DELIRIUM
□ INFECTION
□ AGE ≥ 75
State source:_______________________________
□ RECENT MEDICATION CHANGE
□ PRE-EXISTING COGNITIVE IMPAIRMENT OR
DEMENTIA
(new drugs/drugs stopped/ dose change)
□ METABOLIC DISTURBANCE
□ HEARING OR VISUAL IMPAIRMENT
Electrolyte change, hypoxia, uraemia etc.
□ POLYPHARMACY (≥4 DRUGS)
□ CARDIAC DISEASE
NB especially opiates, benzodiazepines,
anticholinergic, steroids
MI, AF etc
□ GASTROINTESTINAL PROBLEMS
□ PHYSICAL RESTRAINT
GI bleed, constipation etc.
IV line or catheters
□ TRAUMA
Head Injury, hip fracture etc.
□ MULTIPLE CHRONIC ILLNESS
State which
□ DRUG/ALCOHOL HISTORY
Excess (>21 units/week for males and >14
units a week for females), intoxication or
withdrawal
□ GENITOURINARY PROBLEMS
4AT SCORE: _______
Urine retention etc.
ONLY CONTINUE IF DELIRIUM IS DIAGNOSED
When was a diagnosis of delirium made: ________________________
Is there a delirium management plan now in place?
BLOOD TESTS
Tick if done
FBC1
U&E2
LFT3
CRP
TFT
Lab Glucose
Specify Level
□ Yes
□ No
Have the following interventions been performed?
SEWS
Yes
No
PR exam
Yes
No
Bowel opening history
Yes
No
Fluid Balance Chart
Yes
No
Sedation given
Yes
No
If yes give details (type, dose & frequency of administration)
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Have the following interventions been planned?
CXR
Yes
No
CT of Brain
Yes
No
Bladder Scan
Yes
No
ECG
Yes
No
EEG
Yes
No
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Have any additional measures been carried out? E.g. “patient moved to a side room” or “drugs
reviewed” etc.
Please give details below.
1
To exclude any RBC/WCC related abnormalities
To exclude any sodium, potassium, creatinine, calcium, phosphate and urea abnormalities.
3
To exclude any albumin and liver enzymes abnormalities.
2