RASS

Question 1

Negative RASS

Answer 1

• 1 - Drowsy - Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec)
• 2 - Light sedation - Briefly awakens to voice (eyes open & contact <10 sec)
• 3 - Moderate Sedation - Movement or eye opening to voice (no eye contact)
• 4 - Deep Sedation - No response to voice, but movement or eye opening to physical stimulation
• 5 - Unrousable - No response to voice or physical stimulation

Question 2

Positive RASS

Answer 2

+1 - Restless - Anxious, apprehensive, movements not aggressive
+2 - Agitated - Frequent non-purposeful movement, fights ventilator
+3 - Very Agitated - Pulls to remove tubes or catheters; aggressive
+4 - Combative - Combative, violent, immediate danger to staff