RASS
Richmond Agitation-Sedation Scale RASS +4: Combative Overtly combative, violent, immediate danger to staff RASS +3: Very agitated Pulls or removes tube(s) or catheter(s); aggressive RASS +2: Agitated Frequent nonpurposeful movement, fights ventilator RASS +1: Restless Anxious but movements not aggressive or vigorous RASS 0: Alert and calm RASS -1: Drowsy Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 seconds) RASS -2: Light sedation Briefly awakens with eye contact to voice (<10 seconds) RASS -3: Moderate sedation Movement or eye opening to voice (but no eye contact) RASS -4: Deep sedation No response to voice, but movement or eye opening to physical stimulation RASS -5: Unarousable No response to voice or physical stimulation Reference Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003 Jun. 11;289(22):2983-2991. |