RASS SCALE Flashcards
1
Q
When to document RASS scale
A
Before and after administration of sedation medication
2
Q
+4 Combative
A
Overly combative, violent, immediate danger to staff
3
Q
+3 Very agitated
A
Pulls or removes tubes or catheters
Aggressive
4
Q
+2 Agitated
A
Frequent non-purposeful movements
Fights ventilator
5
Q
+1 Restless
A
Anxious but movements not aggressive vigorous
6
Q
0
A
Alert and Calm
7
Q
-1 Drowsy
A
Not fully alert but has sustained awakening
8
Q
-2 Light sedation
A
Briefly awakens with eye contact to voice (<10 seconds)
9
Q
-3 Moderate sedation
A
Movement of eye opening (but no eye contact)
10
Q
-4 Deep sedation
A
No response to voice or eye opening to physical stimulation
11
Q
-5 Unarousable
A
No response to voice or physical stimulation
