SCREENINGS
Assessment
Diagnosis
Anticipated interventions

100

1. Level of alertness –

2. Orientation –

3. Attention –  

4a. Change in thinking or behavior? 

4b. Any hallucinations or paranoia?

WHAT ARE KEY STEPS IN 4AT DELIRIUM SCREEN

100

BEFAST (spell it out) 

What is Balance, Eyes, Face, Arm, Speech % Time

100

A clinical syndrome that may be caused by medical conditions, infections, substance intoxication or medication side effects. It is characterized by an altered level of consciousness, disorientation and decreased ability to focus or sustain attention that develops acutely.

What is Delirium

100

Diagnostic test used to pinpoint the location of a tumor, infection or brain bleed. 

CT scan

200

• Disoriented • Agitated • Lethargic • Drowsy and difficult to arouse • Unable to follow commands

What are commons signs and symptoms of Delirium 

200

PERRLA 

What is pupil assessment 

200

Neuroglycopenic signs and symptoms are signs and symptoms that result from direct central nervous system (CNS) deprivation of glucose. These include behavioral changes, confusion, dizziness, headache, fatigue, seizure, coma, and potential death if not immediately corrected

What is hypoglycemia.  

200

First line treatment for ischemic stroke 

What is thrombolytic therapy

300

patient fall risk evaluation tools used in inpatient healthcare

What is Hester Davis

300

Correctly state their name, location and circumstances

What is orientation

300

Blockage in a blood vessel, resulting in a restricted blood supply to the brain

What is ischemic stroke 

300

Pair of test to determine how fast you blood clots

What is PT and PTT 

400

Critical times to screen for delirium..

What is on admission, every shift, and change in condition. 

400

Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems.

What is a Focused assessment

400

Portable diagnostic tool utilized to differentiate hypoglycemia vs stroke 

What is point of care 

400

Important multidisciplinary consults in stroke post-stroke 

What are PT, OT, and speech consults 

500

 Hoarseness, throat clearing, drooling, aspiration are signs 

What is dysphagia