BSN Tracker

Assessment Tool: Richmond Agitation-Sedation Scale (RASS)

Follow the RASS procedure: observe, then apply verbal and physical stimulation as needed. Select the level that best describes the patient's current response. Compare against the target RASS prescribed for this patient.

Richmond Agitation-Sedation Scale (RASS)

A validated 10-level scale for assessing the level of sedation and agitation in ICU and acute-care patients. Scale ranges from −5 (unarousable) to +4 (combative). Developed by Sessler et al. (2002).

RASS procedure

  1. Observe patient. Is patient alert and calm? Score = 0.
  2. If not alert, call patient's name and ask to open eyes and look at you.
  3. If no response to voice, physically stimulate by shaking the shoulder.
  4. Score based on observed response.