Review of CPOT (pain scale), RASS (sedation scale) and CAM-ICU (delirium) for ICU nurses.

1. CPOT / RASS / CAM-ICU
Assessment for pain, agitation and delirium

2. CPOT / RASS / CAM-ICU
• CPOT, RASS, and CAM-ICU are simple,
inexpensive and non-invasive tools to improve
patient outcomes.
• Pain/Agitation/ Delirium (PAD) assessment will
focus your nursing interventions.

3. CPOT
• The BPS and the CPOT are the most vailid and
reliable behavioural pain scales for use in ICU
patients who can not communicate. Barr (2013)
• CPOT is the assessment tool used for 5.2 and
3A.
• CPOT: 9 times per shift (min) + PRN

4. CPOT
Observe the
patient.
Slowly flex and
relax the
patient’s arm.

5. CPOT
⓿ Facial Expression: No
muscle tension / relaxed
⓿ Body Movement: None
⓿ Muscle Tension:
Relaxed
⓿ Compliance with
Ventilator: Alarms not
active & easy to ventilate

6. CPOT
❷ Facial Expression:
grimacing
❷ Body Movement:
restlessness
❷ Muscle Tension:
very tense
❷ Compliance with
Ventilator: fighting,
asynchrony & alarms

7. RASS
• The RASS and SAS are the most valid and reliable scales for
assessing quality and depth of sedation in ICU patients. Barr (2013)
• Used sedation protocols and checklists to facilitate ICU sedation
and management. Barr (2013)
• Suggests using analgesia first sedation for intubated and
mechanically ventilated patients.Barr (2013)
• RASS is the sedation assessment tool for 5.2 and 3A
• RASS Q1H + PRN
• Goal RASS needs to be ordered

8. RASS

9. RASS

10. RASS

11. CAM-ICU
• Delirium, as a manifestation of acute brain
dysfunction, is an important independent
predictor of negative clinical outcomes in ICU
patients, including increased mortality,
hospital LOS, cost of care, and long-term
cognitive impairment consistent with a
dementia-like state. Barr (2013)

12. CAM-ICU
• Acute Onset
• Disturbances of consciousness
with reduced ability to focus
• Fluctuates over the course of
the day (i.e. variance in RASS)
• Sleep disturbances
• Hallucinations
• Psychomotor Agitation
• Multifactorial
(withdrawal/chronic disease/
medications/infections/advance
d age/sensory deprivation)

13. CAM-ICU

14. • CAM-ICU assessment is essential to detect
delirium.
• Management of delirium:
– Treat the cause of the delirium
– Sleep
– Antipsychotic
– Manage withdrawal symptoms

15. • 5.2 and 3A standard: Q12H and PRN

16. CAM-ICU
• https://www.youtube.com/watch?v=ltd4KYUp
P14

17. Delirium
Agitation
Pain

18. Thank you!

19. References:
• http://www.icudelirium.org/
• http://www.learnicu.org/SiteCollectionDocum
ents/Pain,%20Agitation,%20Delirium.pdf