CPOT / RASS / CAM-ICUAssessment for pain, agitation and delirium

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.

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

CPOTObserve the patient.

Slowly flex and relax the patient’s arm.

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

CPOT❷ Facial Expression: grimacing

❷ Body Movement: restlessness

❷ Muscle Tension: very tense

❷ Compliance with Ventilator: fighting, asynchrony & alarms

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

RASS

RASS

RASS

RASS +1

RASS 0

RASS -5

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)

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/advanced age/sensory deprivation)

CAM-ICU

CAM-ICU

• CAM-ICU assessment is essential to detect delirium.

• Management of delirium: – Treat the cause of the delirium– Sleep– Antipsychotic– Manage withdrawal symptoms

CAM-ICU

• 5.2 and 3A standard: Q12H and PRN

CAM-ICU

• https://www.youtube.com/watch?v=ltd4KYUpP14

CPOT / RASS / CAM-ICU

Poor Outcomes

Delirium

AgitationPain

CPOT, RASS and CAM-ICU are simple, inexpensive, and non-invasive tools to improve patient outcomes.

Thank you!

References:

• http://www.icudelirium.org/

• http://www.learnicu.org/SiteCollectionDocuments/Pain,%20Agitation,%20Delirium.pdf