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140 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

Richmond Agitation Sedation Scale (RASS)*
Sore Term Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
−1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (≥10 seconds) Verbal
−2 Light sedation Briefly awakens with eye contact to voice (<10 seconds) Stimulation
−3 Moderate sedation Movement or eye opening to voice (but not eye contact)
−4 Deep sedation No response to voice, but movement or eye opening Physical
to physical stimulation Stimulation
−5 Unarousable No response to voice or physical stimulation
Procedure for RASS Assessment
1. Observe patient
a. 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.
b. Patient awakens with sustained eye opening and eye contact. (score −1)
c. Patient awakens with eye opening and eye contact, but not sustained. (score −2)
d. 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.
e. Patient has any movement to physical stimulation. (score −4)
f. Patient has no response to any stimulation. (score −5)

77
FIGURE 7.4 Richmond Agitation–Sedation Scale.

The Vancouver Interaction and Calmness Scale
Strongly Mildly Mildly Strongly
Interaction Score /30 agree Agree agree disagree Disagree disagree
Patient interacts 6 5 4 3 2 1
Patient communicates 6 5 4 3 2 1
Information communicated by patient is reliable 6 5 4 3 2 1
Patient cooperates 6 5 4 3 2 1
Patient needs encouragement to respond to questions 1 2 3 4 5 6
Strongly Mildly Mildly Strongly
Calmness Score /30 agree Agree agree disagree Disagree disagree
Patient appears calm 6 5 4 3 2 1
Patient appears restless 1 2 3 4 5 6
Patient appears distressed 1 2 3 4 5 6
Patient is moving around uneasily in bed 1 2 3 4 5 6
Patient is pulling at lines/tubes 1 2 3 4 5 6
80
FIGURE 7.5 Vancouver Interactive and Calmness Scale.

appropriate level of activity for intensive care patients or patient care with prearranged outcomes. Protocol directed
what role BIS might offer in their care. 81,82 Continued sedation is ordered by a doctor, contains guidance regard-
studies to evaluate the efficacy of BIS are required. ing sedation management, and is usually implemented
by nurses although it may have input from pharmacists
or other members of the health care team. Aspects of
SEDATION PROTOCOLS sedation management that are incorporated into seda-
The sedation needs of patients are complex, with various tion protocols include:
reports of patients receiving sub-optimal care and incon- ● the sedation scale to be used, as well as frequency of
sistent practice in this area. 72,83 One of the responses to assessment
this gap in nursing practice has been the development of ● an algorithm-based process for selecting the most
protocols.
appropriate sedative agent
Sedation protocols offer a framework, or algorithm, ● the range of sedative agents that might be considered
within which health professionals can manage specific and associated administration guidelines