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Richmond Agitation-Sedation Scale (RASS)

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

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