Table 1

NEECHAM Confusion Scale

Subscale I Level of responsiveness-information processing

• attention and alertness (0 – 4 points)

• verbal and motor response (0 – 5 points)

• memory and orientation (0 – 5 points)

Subscale II Level of behaviour

• general behaviour and posture (0 – 2 points)

• sensory motor performance (0 – 4 points)

• verbal responses (0 – 4 points)

Subscale III Vital functions

• vital signs (0 – 2 points)

• oxygen saturation level (0 – 2 points)

• urinary continence (0 – 2 points)

Scores: 0 – 19 points = moderate to severe confusion

20 – 24 points = mild or early development of delirium

25 – 30 points = not confused or normal function


Gemert van and Schuurmans BMC Nursing 2007 6:3   doi:10.1186/1472-6955-6-3

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