MODIFIED RICHMOND AGITATION AND SEDATION SCALE (mRASS)
Procedure for RASS Assessment
- Observe patient
- Patient is alert, restless, or agitated. (score 0 to +4)
- If not alert, state patient's name and say to open eyes and look at speaker. Ask 'Describe how you are feeling?'
- Patient awakens with sustained eye opening and eye contact. (score -1)
- Patient awakens with eye opening and eye contact, but not sustained. (score -2)
- Patient has any movement in response to voice but no eye contact. (score -3)
- When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum
- Patient has any movement to physical stimulation. (score -4)
- Patient has no response to any stimulation. (score -5)
| Score | Term | Description |
|---|---|---|
+4 | Combative | No attention; overtly combative, violent, immediate danger to staff |
+3 | Very agitated | Very distractible; repeated calling or touch required to get or keep eye contact or attention.; cannot focus; pulls or removes tube(s) or catheter(s); aggressive; fights environment not people |
+2 | Slightly agitated | Easily distractible; rapidly loses attention; resists care or uncooperative; frequent non-purposeful movement |
+1 | Restless | Slightly distractible; pays attention most of the time; anxious, but cooperative; movements not aggressive or vigorous |
0 | Alert and calm | Pays attention; makes eye contact; aware of surroundings; responds immediately and appropriately to calling name and touch |
-1 | Wakes easily | Slightly drowsy; eye contact<10 sec; not fully alert, but has sustained awakening; eye-opening/eye contact to voice <10 seconds |
-2 | Wakes slowly | Very drowsy; pays attention some of the time; briefly awakens with eye contact to voice >10 seconds |
-3 | Difficult to wake | Repeated calling or touch required to get or keep eye contact or attention; needs repeated stimuli (touch or voice) for attention, movement, or eye opening to voice (but no eye contact) |
-4 | Can't stay awake | Arousable but no attention; no response to voice, but movement or eye opening to physical stimulation |
-5 | Unarousable | No response to voice or physical stimulation |