Phone: 888-581-4448

This email address is being protected from spambots. You need JavaScript enabled to view it.

LiveZilla Live Chat Software

Richmond Agitation Sedation Scale (RASS)

Richmond Agitation Sedation Scale (RASS) *

 

Score                 Term                                Description

+4                    Combative                         Overtly combative, violent, immediate danger to staff

+3                    Very agitated                     Pulls or removes tube(s) or catheter(s); aggressive

+2                    Agitated                             Frequent non-purposeful movement, fights ventilator

+1                    Restless                              Anxious but movements not aggressive vigorous

0                     Alert and calm

-1                    Drowsy                              Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds)        Verbal Stimulation

-2                    Light sedation                    Briefly awakens with eye contact to voice (<10 seconds)                                                                  Verbal Stimulation

-3                    Moderate sedation              Movement or eye opening to voice (but no eye contact)                                                                  Verbal Stimulation

-4                    Deep sedation                    No response to voice, but movement or eye opening to physical stimulation                                     Physical Stimulation

-5                   Unarousable                       No response to voice or physical stimulation                                                                                      Physical Stimulation

 

 

Procedure for RASS Assessment

1. Observe patient

    a. Patient is alert, restless, or agitated.                                                                       (score 0 to +4)

2. If not alert, state patient’s name and say to open eyes and look at speaker.

    b. Patient awakens with sustained eye opening and eye contact.                               (score –1)

    c. Patient awakens with eye opening and eye contact, but not sustained.                  (score –2)

    d. Patient has any movement in response to voice but no eye contact.                     (score –3)

3. When no response to verbal stimulation, physically stimulate patient by 

    shaking shoulder and/or rubbing sternum.

    e. Patient has any movement to physical stimulation.                                               (score –4)

    f. Patient has no response to any stimulation.                                                           (score –5)

 

* Sessler CN, Gosnell M, Grap MJ, Brophy GT, O'Neal PV, Keane KA et al. The Richmond Agitation-

Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002;

166:1338-1344.

* Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status

over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS).

JAMA 2003; 289:2983-2991.