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RASS (Richmond Agitation-Sedation Scale)
Assess level of sedation and agitation in ICU patients
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RASS Level
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+4 Combative - Overtly combative, violent
+3 Very agitated - Pulls/removes tubes, aggressive
+2 Agitated - Frequent non-purposeful movement
+1 Restless - Anxious, apprehensive but not aggressive
0 Alert and calm
-1 Drowsy - Not fully alert, sustained awakening to voice
-2 Light sedation - Briefly awakens to voice
-3 Moderate sedation - Movement to voice, no eye contact
-4 Deep sedation - No response to voice, movement to physical stimulation
-5 Unarousable - No response to voice or physical stimulation
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