The Richmond Agitation-Sedation Scale (RASS) assesses agitation and sedation in adult intensive care patients. Scores range from +4 to −5[^1].
Score | Term | Description |
|---|---|---|
+4 | Combative | The patient is violent and poses an immediate danger to staff. |
+3 | Very agitated | The patient pulls at tubes or catheters or behaves aggressively. |
+2 | Agitated | The patient frequently moves without an apparent purpose or fights the ventilator. |
+1 | Restless | The patient appears anxious but does not make aggressive or vigorous movements. |
0 | Alert and calm | The patient is alert and calm. |
-1 | Drowsy | The patient is not fully alert but maintains eye contact for more than ten seconds in response to voice. |
-2 | Light sedation | The patient briefly awakens to voice and maintains eye contact for less than ten seconds. |
-3 | Moderate sedation | The patient moves or opens the eyes to voice but does not establish eye contact. |
-4 | Deep sedation | The patient does not respond to voice but moves in response to physical stimulation. |
-5 | Unarousable | The patient responds neither to voice nor to physical stimulation. |
The score reflects observed behavior and the response to voice or physical stimulation[^1].
Assessment in three steps
The patient is observed first.
If the patient is not alert, verbal stimulation is used and the duration of eye contact is assessed.
If there is no response to voice, the response to physical stimulation is assessed[^2].
RASS and delirium assessment
The RASS score describes arousal and the degree of agitation or sedation. Delirium is assessed separately, for example with the CAM-ICU. A RASS score alone does not diagnose delirium[^3].
