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Nursing Delirium Screening Scale (Nu-DESC)

Nursing Delirium Screening Scale — Nu-DESC (5 items · 0–2 each · Max: 10)

Disorientation

Disoriented to person, place, time, or misinterpreting current events.

Inappropriate Behavior

Inappropriate actions: pulling at tubes, attempting to leave bed, wandering.

Inappropriate Communication

Speech that is incoherent, irrelevant, or does not match the situation.

Illusions / Hallucinations

Seeing or hearing things that are not there; misinterpreting real sensory input.

Psychomotor Retardation

Delayed responsiveness, sparse spontaneous movement or speech, unarousable.

Delirium Screening

Rate each of the 5 domains based on behaviour observed over the current nursing shift.

Guidelines & Evidence

Verified

Last Review: 2026

When to Use

Continuous or shift-by-shift assessment of cognitive and psychomotor delirium symptoms

Bedside screening for adult patients in palliative care, oncology units, and general medical wards

Post-operative monitoring within Post-Anesthetic Care Units (PACU)

Monitoring hypoactive, hyperactive, and mixed motor subtypes of delirium

When NOT to Use

The scale relies on clinical observation; it should not replace comprehensive diagnostic assessments (e.g., DSM-5-TR or psychiatric consultation) when clinical suspicion remains high despite a low screening score.

Last Comprehensive Review: 2026

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