RASS Flashcards
1
Q
0
A
Alert and calm
2
Q
+1
A
Restless:
Anxious but movements not aggressive vigorous
3
Q
+2
A
Agitated:
Frequent non-purposeful movement, fights ventilator
4
Q
+3
A
Very agitated:
Pulls or removes tube(s) or catheter(s); aggresive
5
Q
+4
A
Combative:
Overtly combative, violent, immediate danger to staff
6
Q
-1
A
Drowsy:
Not fully alert, but ha sustained awakening
Eye contact to voice ≥10 seconds
7
Q
-2
A
Light sedation:
Briefly awakens with eye contact to voice (<10 seconds)
8
Q
-3
A
Moderate sedation:
Movement or eye opening to voice
(but no eye contact)
9
Q
-4
A
Deep sedation:
NO response to voice, but movement or eye opening to physical stimulation
10
Q
-5
A
Unarousable:
No response to voice or physical stimulation
