Page 47 - Critical Care Notes

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Procedure for RASS Assessment—cont’d

Procedure Patient Assessment Score
3. When no e. Patient has any movement to –4
response to physical stimulation.
verbal f. Patient has no response to –5
stimulation, any stimulation.
physically
stimulate
patient by
shaking
shoulder
and/or rubbing
sternum.
Reprinted with permission from Vanderbilt University. http://www.icudelirium.org/docs/RASS.pdf.

Sedation-Agitation Scale (SAS)

Score Level of Sedation-Agitation Response
7 Dangerous agitation Pulling at endotracheal tube, thrash-
ing, climbing over bed rails
6 Very agitated Does not calm, requires restraints,
bites endotracheal tube
5 Agitated Attempts to sit up but calms to
verbal instructions
4 Calm and cooperative Obeys commands
3 Sedated Difficult to rouse, obeys simple
commands
2 Very sedated Rouses to stimuli; does not obey
commands
1 Unarousable Minimal or no response to noxious
stimuli
Reprinted with permission from Riker, R, Fraser, GL, and Cox, PM. Continuous infusion of
haloperidol controls agitation in critically ill patients. Crit Care Med 22(3):433–440, 1994.

BASICS