The document discusses tools for assessing pain, agitation, and delirium in ICU patients: CPOT for pain, RASS for sedation level, and CAM-ICU for delirium. CPOT, RASS, and CAM-ICU are simple, non-invasive tools that can improve patient outcomes by focusing nursing interventions. The document provides details on how to use each tool, including how often they should be administered. It also discusses the importance of detecting and managing delirium in ICU patients.

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