Richmond Agitation-Sedation Scale (RASS)
Assesses the level of sedation or agitation in critically ill patients.
The Richmond Agitation-Sedation Scale (RASS) is an assessment tool for patients in intensive care, used to quantify the level of agitation or sedation of the patient.
Select the score that best represents the patient's current state:
| Score | Description |
|---|---|
| +4 | Very agitated: Aggressive, dangerous to self and others. |
| +3 | Agitated: Pulls or removes tubes/catheters, combative behavior. |
| +2 | Restless: Frequent, non-purposeful movements, without aggression. |
| +1 | Anxious/Restless: Anxious, with non-aggressive movements. |
| 0 | Alert and calm: Ideal state. |
| -1 | Drowsy: Awakens to voice for >10s, sustained eye contact. |
| -2 | Light sedation: Brief eye contact. |
| -3 | Moderate sedation: Moves without eye contact. |
| -4 | Deep sedation: Reacts to painful stimulus. |
| -5 | Unresponsive: No response to any stimulus. |
Sessler CN, Gosnell MS, Grap MJ et al. The Richmond Agitation-Sedation Scale (RASS): Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338-44. Available at: https://pubmed.ncbi.nlm.nih.gov/12433696/
Universidade Federal de Pelotas – UFPel. Escala de Agitação e Sedação de Richmond (RASS). Available at: https://dms.ufpel.edu.br/static/bib/apoio/escala_de_rass.pdf