Step 1: Level of Consciousness Assessment RASS: RICHMOND AGITATION‒SEDATION SCALE
Scale
Label
Description
+ 4 + 3 + 2 + 1
COMBATIVE
Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non- purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive
VERY AGITATED
AGITATED RESTLESS
0
ALERT & CALM
Spontaneously pays attention to caregiver
Not fully alert, but has sustained awakening to voice (eye opening & contact > 10 seconds) Briefly awakens to voice (eyes open & contact < 10 seconds)
- 1
DROWSY
- 2 - 3
LIGHT SEDATION
MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is ≥ -3, proceed to CAM-ICU (is patient CAM-ICU positive or negative)
No response to voice, but movement or eye opening to physical stimulation
- 4
DEEP SEDATION
- 5
UNAROUSABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
Sessler et al. 2002. PMID: 12421743.
Ely et al. 2003. PMID: 12799407
28 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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