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Richmond Agitation Sedation Scale (RASS)

Purpose: To evaluate the status of a patient over the continuum of agitation and sedation in the intensive care unit using the Richmond Agitation Sedation Scale (RASS).

Description

The Richmond Agitation-Sedation Scale (RASS) can be used to monitor the level of agitation (excited sensorium) and sedation (depressed sensorium) for a patient in the intensive care unit (ICU).


 

Behavioral ranges:

(1) agitated or anxious: 1 to 4

(2) neutral: 0

(3) sedated: -1 to -5

 

Clinical Status

RASS

combative (violent, dangerous to staff)

4

very agitated (pulling on or removing catheters)

3

agitated (fighting ventilator)

2

anxious

1

spontaneously alert, calm and not agitated

0

able to maintain eye contact >= 10 seconds

-1

able to maintain eye contact < 10 seconds

-2

eye opening but no eye contact

-3

eye opening or movement with physical or painful stimuli

-4

unresponsive to physical or painful stimuli (deeply comatose)

-5

 


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Specialty

Objective

ICD-10