Sim Day Flashcards
What is the procedure for RASS?
- Observe patient.
- If not alert, state patient’s name and ask to open eyes and look at speaker.
- When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum.
What does +4 on the RASS scale represent?
Combative
Overly combative, violent, immediate danger to staff
What does +3 on the RASS scale represent?
Very agitated
Pulls or removes tubes and catheters; aggressive
What does +2 on the RASS scale represent?
Agitated
Frequent, non-purposeful movements. Fights ventilator.
What does +1 on the RASS scale represent?
Restless
Anxious, but movements are not agressive or vigorous
What does 0 on the RASS scale represent?
Alert and calm
What does -1 represent on the RASS scale?
Drowsy
Not fully alert, but has sustained awakening (eye contact /eye opening) to voice (>= 10 seconds)
What does -2 on the RASS scale represent?
Light sedation
Briefly awakens with eye contact to voice (<10 seconds)
What does -3 on the RASS scale represent?
Moderate sedation
Movement or eye opening to voice (but no eye contact)
What does -4 on the RASS scale represent?
Deep sedation
No response to voice, but movement and eye opening to physical stimulation
What does -5 on the RASS scale represent?
Unarousable
No response to voice or physical stimulation
Glasgow Scale: Check
For factors interfering with communication, inability to respond and other injuries
Glasgow Scale: Observe
Eye opening, content of speech and movements of right and left side
Glasgow Scale: Stimulate
Sound: Spoken or shouted request
Physical: Pressure on finger tip, trapezius or suprasternal notch
Glasgow Scale: Rate
Assign according to highest response observed
