Richmond Agitation Sedation Scale (RASS)

+ 4     Combative, violent, danger to staff
+ 3     Pulls or removes tube(s) or catheters; aggressive
+ 2    Frequent nonpurposeful movement, fights ventilator
+ 1    Anxious, apprehensive , but not aggressive
0       Alert and calm
– 1    Awakens to voice (eye opening/contact) >10 sec
– 2    Light sedation, briefly awakens to voice (eye
opening/contact) <10 sec
– 3    Moderate sedation, movement or eye opening. No eye
contact
– 4    Deep sedation, no response to voice, but movement or
eye opening to physical stimulation
– 5    Unarousable, no response to voice or physical
stimulation

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