Richmond Agitation-Sedation Scale
Medical scale used to measure agitation and sedation
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Richmond Agitation-Sedation Scale (RASS) is a medical scale used to measure the agitation or sedation level of a person. It was developed with efforts of different practitioners, represented by physicians, nurses and pharmacists.[1][2]
The RASS can be used in all hospitalized patients to describe their level of alertness or agitation.[3] It is however mostly used in mechanically ventilated patients in order to avoid over and under-sedation. Obtaining a RASS score is the first step in administering the Confusion Assessment Method in the ICU (CAM-ICU),[4] a tool to detect delirium in intensive care unit patients.
The RASS is one of many sedation scales used in medicine. Other scales include the Ramsay scale, the Sedation-Agitation-Scale, and the COMFORT scale for pediatric patients.
Score
| Score | Term | Description |
|---|---|---|
| +4 | Combative | Overtly combative or violent; immediate danger to staff |
| +3 | Very agitated | Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff |
| +2 | Agitated | Frequent nonpurposeful movement or patient–ventilator dyssynchrony |
| +1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
| 0 | Alert and calm | Spontaneously pays attention to caregiver |
| -1 | Drowsy | Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice |
| -2 | Light sedation | Briefly (less than 10 seconds) awakens with eye contact to voice |
| -3 | Moderate sedation | Any movement (but no eye contact) to voice |
| -4 | Deep sedation | No response to voice, but any movement to physical stimulation |
| -5 | Unarousable | No response to voice or physical stimulation |
Evaluation
RASS was designed to have precise, unambiguous definitions for levels of sedation that rely on an assessment of arousal, cognition, and sustainability using common responses common stimuli presented in a logical progression. To better use it these stimuli should presented to the patient as follows:
- Observe patient. Is patient alert and calm (score 0)?
- Does patient have behavior that is consistent with restlessness or agitation (score +1 to +4 using the criteria listed at the , under Description)?
- If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
- Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1).
- Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2).
- Patient has any movement in response to voice, excluding eye contact (score -3).
- If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder.
- Patient has any movement to physical stimulation (score -4).
- Patient has no response to voice or physical stimulation (score -5).
