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



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