RASS (Richmond Agitation Sedation Scale) 4 - Combative - Overtly combative, violent, immediate danger to staff 3 - Very agitated - Pulls or removes tubes or catheters; aggressive 2 - Agitated - Frequent non-purposeful mvmt, fights ventilator 1 - Restless - Anxious but movements not aggressive or vigorous 0 - Alert and calm -1 - Drowsy - Sustained awakening to voice (≥10sec) -2 - Light sedation - Briefly awakens with eye contact to voice (<10 sec) -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 -5 - Cannot be aroused - No response to voice or physical stimulation #RASS #Richmond #Agitation #Sedation #Scale #diagnosis #nursing
