Richmond Agitation-Sedation Scale (RASS)
Ranks agitation and possibility for sedation.
See Evidence for definitions of criteria.
When to Use
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- Patients with a RASS of -3 or less should have their sedation decreased or modified in order to achieve a RASS of -2 to 0.
- Patients with a RASS of 2 to 4 are not sedated enough and should be assessed for pain, anxiety, or delirium. The underlying etiology of the agitation should be investigated and appropriately treated to achieve a RASS of -2 to 0.
- A RASS score should be obtained on all hospitalized patients and at regular interval in all mechanically ventilated patients.
- Unless a patient meets indication for deep sedation, a protocol for minimal sedation (RASS -2 to 0) should be used.
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