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Back| Score | Term | Description |
|---|---|---|
| +4 | Aggressive | Clear violent behavior, a threat to staff |
| +3 | Very Agitated | Trying to pull out the breathing tube, feeding tube, or IV |
| +2 | Agitated Anxious | Frequent meaningless movements, unable to cooperate with the ventilator |
| +1 | Restless Anxious | Anxious and tense but with only slight physical movement |
| 0 | Awake Calm | Awake in a natural state |
| -1 | Somnolent | Not fully awake, but can be awakened by voice and maintain alertness (eyes open and making eye contact), >10s |
| -2 | Mildly Sedated | Briefly maintains alertness after being awakened by voice, <10s |
| -3 | Moderately Sedated | Reacting to sound or opening eyes (but no eye contact) |
| -4 | Severely Sedated | Reacting to physical stimulation or opening eyes |
| -5 | Comatose | No response to sound or physical stimulation |
Explanation
Mainly used to monitor the sedation level of patients in the ICU or other settings.
Steps for performing the RASS score:
Step 1: Observe the patient
● Is the patient awake, restless, or agitated? Score: 0~+4
Step 2: If the patient is not awake, call the patient's name to awaken them and ask them to look at the speaker
● The patient can open their eyes, has eye contact, and maintains that state Score: -1
● The patient can open their eyes, has eye contact, but cannot maintain it Score: -2
● The patient can open their eyes or has other responses but no eye contact Score: -3
Step 3: If the patient does not respond to sound, shake their shoulder or touch their chest to awaken them
● The patient responds to physical stimulation or opens their eyes Score: -4
● The patient shows no response to any stimulation Score: -5
