Nursing Delirium Screening Scale13
| Features and description | Symptom rating |
| 1. Disorientation Verbal or behavioural manifestation of not being oriented to time or place or misperceiving persons in the environment | 0—absent 1—present but not severe 2—severe |
| 2. Inappropriate behaviour Behaviour inappropriate to place and/or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when that is contraindicated, and the like | 0—absent 1—present but not severe 2—severe |
| 3. Inappropriate communication Communication inappropriate to place and/or for the person; e.g., incoherence, noncommunicativeness, nonsensical or unintelligible speech | 0—absent 1—present but not severe 2—severe |
| 4. Illusions/hallucinations Seeing or hearing things that are not there; distortions of visual objects | 0—absent 1—present but not severe 2—severe |
| 5. Psychomotor retardation Delayed responsiveness, few or no spontaneous actions/words; e.g., when the patient is prodded, reaction is deferred and/or the patient is unarousable | 0—absent 1—present but not severe 2—severe |
| Total score |