ADD-ONS / SCALES
RASS (Richmond Agitation-Sedation Scale)
Created 13/01/2023, last revision 13/01/2023
- the test assesses the quantitative component of consciousness and the level of psychomotor activity
- mostly it is used in mechanically ventilated patients in order to avoid over and under-sedation
- timing is important; reduce sedation 1-2h before testing
- start with observing the patient
- patient is alert, in the normal state (0)
- patient is hyperactive (score +1 to +4)
- patient is alert, in the normal state (0)
- if not alert, state the patient’s name and ask him/her to open eyes and look at the speaker
- patient awakens with sustained eye opening and eye contact (score –1)
- patient awakens with eye opening and eye contact, but not sustained (score –2)
- patient has any movement in response to voice but no eye contact (score –3)
- grades -1 to -3 correspond to somnolence of varying degrees, the patient responds to verbal stimulus and can potentially be further tested for delirium
- when no response to verbal stimulation, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum
- any movement to physical stimulation (score –4)
- no response to any stimulation (score –5)
- grades -4 and -5 correspond to a more profound disturbance of consciousness (sopor – coma) and the patient cannot be further tested for delirium
RASS (Richmond Agitation-Sedation Scale) |
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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 | somnolent /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) | |
-3 | moderate sedation | movement or eye opening to voice (but no eye contact) | |
-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 |