"improving intensive care in Scotland"

Richmond Agitation and Sedation Scale (RASS)

 

Score

Term

Description

+ 4

Combatative Overtly combative, violent, immediate danger to staff

+ 3

Very agitated Pulls and removes tube(s) or catheter(s); aggressive

+ 2

Agitated Frequent non-purposeful movement; fights ventilator

+ 1

Restless Anxious but movements not aggressive or vigorous

0

Alert Calm

- 1

Drowsy Not fully alert. Eye opening to voice >10 sec

- 2

Light sedation Briefly awakens. Eye opening to voice < 10 sec

- 3

Moderate sedation Movement or eye opening to voice. No eye contact

- 4

Deep sedation No response to voice. Movement/eye opening to pain

- 5

Unrousable No response to voice or physical stimulation

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