The Richmond Agitation Sedation Score (RASS)

Instructions

1. Observe patient. Is patient alert and calm (score 0)?

2. Does patient have behavior that is consistent with restlessness or agitation?
Assign score +1 to +4 using the criteria listed above.

3. If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.

Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1).

Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2).

Patient has any movement in response to voice, excluding eye contact (score -3).

4. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response.

Patient has any movement to physical stimulation (score -4).

Patient has no response to voice or physical stimulation (score -5).