#  MODIFIED RICHMOND AGITATION AND SEDATION SCALE (mRASS) 

 



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#### Procedure for RASS Assessment

1. Observe patient
    1. Patient is alert, restless, or agitated. **(score 0 to +4)**
2. If not alert, state patient's name and say to open eyes and look at speaker. Ask 'Describe how you are feeling?'
    1. Patient awakens with sustained eye opening and eye contact. **(score -1)**
    2. Patient awakens with eye opening and eye contact, but not sustained. **(score -2)**
    3. Patient has any movement in response to voice but no eye contact. **(score -3)**
3. When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum
    1. Patient has any movement to physical stimulation. **(score -4)**
    2. Patient has no response to any stimulation. **(score -5)**

SortScoreTermDescription+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