sedation assessment description sedation assessment...

2
RICHMOND AGITATION-SEDATION SCALE (RASS) Scale Label Description STEP Sedation Assessment -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later T O U C H +4 COMBATIVE Combative, violent, immediate danger to staff +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +2 AGITATED Frequent non-purposeful movement, fights ventilator +1 RESTLESS Anxious, apprehensive, movements not aggressive 0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) V O I C E Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991 RICHMOND AGITATION-SEDATION SCALE (RASS) Scale Label Description STEP Sedation Assessment -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later T O U C H +4 COMBATIVE Combative, violent, immediate danger to staff +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +2 AGITATED Frequent non-purposeful movement, fights ventilator +1 RESTLESS Anxious, apprehensive, movements not aggressive 0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) V O I C E Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991 RICHMOND AGITATION-SEDATION SCALE (RASS) Scale Label Description STEP Sedation Assessment -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later T O U C H +4 COMBATIVE Combative, violent, immediate danger to staff +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +2 AGITATED Frequent non-purposeful movement, fights ventilator +1 RESTLESS Anxious, apprehensive, movements not aggressive 0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) V O I C E Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991 RICHMOND AGITATION-SEDATION SCALE (RASS) Scale Label Description STEP Sedation Assessment -4 DEEP SEDATION No response to voice, but movement or eye opening to physical stimulation -5 UNAROUSEABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later T O U C H +4 COMBATIVE Combative, violent, immediate danger to staff +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +2 AGITATED Frequent non-purposeful movement, fights ventilator +1 RESTLESS Anxious, apprehensive, movements not aggressive 0 ALERT & CALM Spontaneously pays attention to caregiver -1 DROWSY Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) V O I C E Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991

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RIC

HM

ON

D A

GIT

ATI

ON

-SED

ATI

ON

SC

ALE

(RA

SS)

Sc

ale

L

abel

D

escr

iptio

n

STEP

Seda

tion

Ass

essm

ent

-4

D

EEP

SED

ATI

ON

No

resp

onse

to v

oice

, but

mov

emen

t or e

ye o

peni

ng

to p

hysi

cal s

timul

atio

n

-5

U

NA

RO

USE

AB

LE

N

o re

spon

se to

voi

ce o

r phy

sica

l stim

ulat

ion

If R

ASS

is -4

or -

5

STO

P (p

atie

nt u

ncon

scio

us),

REC

HEC

K la

ter

T O U C H

+4

CO

MB

ATI

VE

Com

bativ

e, v

iole

nt, i

mm

edia

te d

ange

r to

staf

f +3

VE

RY

AG

ITA

TED

Pulls

to re

mov

e tu

bes

or c

athe

ters

; agg

ress

ive

+2

AG

ITA

TED

Fr

eque

nt n

on-p

urpo

sefu

l mov

emen

t, fig

hts

vent

ilato

r +1

R

ESTL

ESS

Anx

ious

, app

rehe

nsiv

e, m

ovem

ents

not

agg

ress

ive

0

A

LER

T &

CA

LM

Sp

onta

neou

sly

pays

atte

ntio

n to

car

egiv

er

-1

DR

OW

SY

Not

fully

ale

rt, b

ut h

as s

usta

ined

aw

aken

ing

to v

oice

(e

ye o

peni

ng &

con

tact

>10

sec

)

-2

LIG

HT

SED

ATI

ON

Brie

fly a

wak

ens

to v

oice

(eye

s op

en &

con

tact

<10

sec

)

-3

MO

DER

ATE

SED

ATI

ON

M

ovem

ent o

r eye

ope

ning

to v

oice

(no

eye

cont

act)

If R

ASS

is ≥

-3 p

roce

ed to

CA

M-IC

U (I

s pa

tient

CA

M-IC

U p

ositi

ve o

r neg

ativ

e?)

V O I C E

Ses

sler

, et a

l., A

m J

Rep

ir C

rit C

are

Med

200

2, 1

66: 1

338-

1344

E

ly, e

t al.,

JA

MA

2003

; 286

, 298

3-29

91

RIC

HM

ON

D A

GIT

ATI

ON

-SED

ATI

ON

SC

ALE

(RA

SS)

Sc

ale

L

abel

D

escr

iptio

n

STEP

Seda

tion

Ass

essm

ent

-4

D

EEP

SED

ATI

ON

No

resp

onse

to v

oice

, but

mov

emen

t or e

ye o

peni

ng

to p

hysi

cal s

timul

atio

n

-5

U

NA

RO

USE

AB

LE

N

o re

spon

se to

voi

ce o

r phy

sica

l stim

ulat

ion

If R

ASS

is -4

or -

5

STO

P (p

atie

nt u

ncon

scio

us),

REC

HEC

K la

ter

T O U C H

+4

CO

MB

ATI

VE

Com

bativ

e, v

iole

nt, i

mm

edia

te d

ange

r to

staf

f +3

VE

RY

AG

ITA

TED

Pulls

to re

mov

e tu

bes

or c

athe

ters

; agg

ress

ive

+2

AG

ITA

TED

Fr

eque

nt n

on-p

urpo

sefu

l mov

emen

t, fig

hts

vent

ilato

r +1

R

ESTL

ESS

Anx

ious

, app

rehe

nsiv

e, m

ovem

ents

not

agg

ress

ive

0

A

LER

T &

CA

LM

Sp

onta

neou

sly

pays

atte

ntio

n to

car

egiv

er

-1

DR

OW

SY

Not

fully

ale

rt, b

ut h

as s

usta

ined

aw

aken

ing

to v

oice

(e

ye o

peni

ng &

con

tact

>10

sec

)

-2

LIG

HT

SED

ATI

ON

Brie

fly a

wak

ens

to v

oice

(eye

s op

en &

con

tact

<10

sec

)

-3

MO

DER

ATE

SED

ATI

ON

M

ovem

ent o

r eye

ope

ning

to v

oice

(no

eye

cont

act)

If R

ASS

is ≥

-3 p

roce

ed to

CA

M-IC

U (I

s pa

tient

CA

M-IC

U p

ositi

ve o

r neg

ativ

e?)

V O I C E

Ses

sler

, et a

l., A

m J

Rep

ir C

rit C

are

Med

200

2, 1

66: 1

338-

1344

E

ly, e

t al.,

JA

MA

2003

; 286

, 298

3-29

91

RIC

HM

ON

D A

GIT

ATI

ON

-SED

ATI

ON

SC

ALE

(RA

SS)

Sc

ale

L

abel

D

escr

iptio

n

STEP

Seda

tion

Ass

essm

ent

-4

D

EEP

SED

ATI

ON

No

resp

onse

to v

oice

, but

mov

emen

t or e

ye o

peni

ng

to p

hysi

cal s

timul

atio

n

-5

U

NA

RO

USE

AB

LE

N

o re

spon

se to

voi

ce o

r phy

sica

l stim

ulat

ion

If R

ASS

is -4

or -

5

STO

P (p

atie

nt u

ncon

scio

us),

REC

HEC

K la

ter

T O U C H

+4

CO

MB

ATI

VE

Com

bativ

e, v

iole

nt, i

mm

edia

te d

ange

r to

staf

f +3

VE

RY

AG

ITA

TED

Pulls

to re

mov

e tu

bes

or c

athe

ters

; agg

ress

ive

+2

AG

ITA

TED

Fr

eque

nt n

on-p

urpo

sefu

l mov

emen

t, fig

hts

vent

ilato

r +1

R

ESTL

ESS

Anx

ious

, app

rehe

nsiv

e, m

ovem

ents

not

agg

ress

ive

0

A

LER

T &

CA

LM

Sp

onta

neou

sly

pays

atte

ntio

n to

car

egiv

er

-1

DR

OW

SY

Not

fully

ale

rt, b

ut h

as s

usta

ined

aw

aken

ing

to v

oice

(e

ye o

peni

ng &

con

tact

>10

sec

)

-2

LIG

HT

SED

ATI

ON

Brie

fly a

wak

ens

to v

oice

(eye

s op

en &

con

tact

<10

sec

)

-3

MO

DER

ATE

SED

ATI

ON

M

ovem

ent o

r eye

ope

ning

to v

oice

(no

eye

cont

act)

If R

ASS

is ≥

-3 p

roce

ed to

CA

M-IC

U (I

s pa

tient

CA

M-IC

U p

ositi

ve o

r neg

ativ

e?)

V O I C E

Ses

sler

, et a

l., A

m J

Rep

ir C

rit C

are

Med

200

2, 1

66: 1

338-

1344

E

ly, e

t al.,

JA

MA

2003

; 286

, 298

3-29

91

RIC

HM

ON

D A

GIT

ATI

ON

-SED

ATI

ON

SC

ALE

(RA

SS)

Sc

ale

L

abel

D

escr

iptio

n

STEP

Seda

tion

Ass

essm

ent

-4

D

EEP

SED

ATI

ON

No

resp

onse

to v

oice

, but

mov

emen

t or e

ye o

peni

ng

to p

hysi

cal s

timul

atio

n

-5

U

NA

RO

USE

AB

LE

N

o re

spon

se to

voi

ce o

r phy

sica

l stim

ulat

ion

If R

ASS

is -4

or -

5

STO

P (p

atie

nt u

ncon

scio

us),

REC

HEC

K la

ter

T O U C H

+4

CO

MB

ATI

VE

Com

bativ

e, v

iole

nt, i

mm

edia

te d

ange

r to

staf

f +3

VE

RY

AG

ITA

TED

Pulls

to re

mov

e tu

bes

or c

athe

ters

; agg

ress

ive

+2

AG

ITA

TED

Fr

eque

nt n

on-p

urpo

sefu

l mov

emen

t, fig

hts

vent

ilato

r +1

R

ESTL

ESS

Anx

ious

, app

rehe

nsiv

e, m

ovem

ents

not

agg

ress

ive

0

A

LER

T &

CA

LM

Sp

onta

neou

sly

pays

atte

ntio

n to

car

egiv

er

-1

DR

OW

SY

Not

fully

ale

rt, b

ut h

as s

usta

ined

aw

aken

ing

to v

oice

(e

ye o

peni

ng &

con

tact

>10

sec

)

-2

LIG

HT

SED

ATI

ON

Brie

fly a

wak

ens

to v

oice

(eye

s op

en &

con

tact

<10

sec

)

-3

MO

DER

ATE

SED

ATI

ON

M

ovem

ent o

r eye

ope

ning

to v

oice

(no

eye

cont

act)

If R

ASS

is ≥

-3 p

roce

ed to

CA

M-IC

U (I

s pa

tient

CA

M-IC

U p

ositi

ve o

r neg

ativ

e?)

V O I C E

Ses

sler

, et a

l., A

m J

Rep

ir C

rit C

are

Med

200

2, 1

66: 1

338-

1344

E

ly, e

t al.,

JA

MA

2003

; 286

, 298

3-29

91

Con

fusi

on A

sses

smen

t Met

hod

for t

he IC

U (C

AM

-ICU

) ST

EPD

ELIR

IUM

ASS

ESSM

ENT

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

Upo

sitiv

eD

ELIR

IUM

Pre

sent

4. D

isor

gani

zed

Thin

king

:

1.

Will

a s

tone

floa

t on

wat

er?

2. A

re th

ere

fish

in th

e se

a?

3. D

oes

one

poun

d w

eigh

mor

e th

an tw

o?

4. C

an y

ou u

se a

ham

mer

to p

ound

a n

ail?

Com

man

d: “

Hol

dup

this

man

y fin

gers

” (H

old

up 2

fing

ers)

“N

ow d

o th

e sa

me

thin

g w

ith th

e ot

her h

and”

(Do

not d

emon

stra

te)

OR

Add

one

mor

e fin

ger”

(If p

atie

nt u

nabl

e to

mov

e bo

th a

rms)

0 - 1

Erro

r

> 1

Erro

r

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

3. A

ltere

d Le

vel o

f Con

scio

usne

ss

Cur

rent

RA

SS le

vel (

thin

k ba

ck to

sed

atio

n as

sess

men

t in

Step

1)

RA

SS o

ther

th

an z

ero

RA

SS =

zer

o

2. In

atte

ntio

n:

“Squ

eeze

my

hand

whe

n I s

ay th

e le

tter ‘

A’.”

Rea

d th

e fo

llow

ing

sequ

ence

of l

ette

rs: S

A V

E A

H A

A R

T

ERR

OR

S : N

o sq

ueez

e w

ith ‘A

’ & S

quee

ze o

n le

tter o

ther

than

‘A’

If u

nabl

e to

com

plet

e Le

tters

P

ictu

res

0 - 2

Er

rors

> 2

Erro

rs

NO

1. A

cute

Cha

nge

or F

luct

uatin

g C

ours

e of

Men

tal S

tatu

s:

Is th

ere

an a

cute

cha

nge

from

men

tal s

tatu

s ba

selin

e?

OR

Has

the

patie

nt’s

men

tal s

tatu

s flu

ctua

ted

durin

g th

e pa

st 2

4 ho

urs?

YES

Cop

yrig

ht ©

200

2, E

. Wes

ley

Ely

, MD

, MP

H a

nd V

ande

rbilt

Uni

vers

ity, a

ll rig

hts

rese

rved

• • ••

Con

fusi

on A

sses

smen

t Met

hod

for t

he IC

U (C

AM

-ICU

) ST

EPD

ELIR

IUM

ASS

ESSM

ENT

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

Upo

sitiv

eD

ELIR

IUM

Pre

sent

4. D

isor

gani

zed

Thin

king

:

1.

Will

a s

tone

floa

t on

wat

er?

2. A

re th

ere

fish

in th

e se

a?

3. D

oes

one

poun

d w

eigh

mor

e th

an tw

o?

4. C

an y

ou u

se a

ham

mer

to p

ound

a n

ail?

Com

man

d: “

Hol

dup

this

man

y fin

gers

” (H

old

up 2

fing

ers)

“N

ow d

o th

e sa

me

thin

g w

ith th

e ot

her h

and”

(Do

not d

emon

stra

te)

OR

Add

one

mor

e fin

ger”

(If p

atie

nt u

nabl

e to

mov

e bo

th a

rms)

0 - 1

Erro

r

> 1

Erro

r

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

3. A

ltere

d Le

vel o

f Con

scio

usne

ss

Cur

rent

RA

SS le

vel (

thin

k ba

ck to

sed

atio

n as

sess

men

t in

Step

1)

RA

SS o

ther

th

an z

ero

RA

SS =

zer

o

2. In

atte

ntio

n:

“Squ

eeze

my

hand

whe

n I s

ay th

e le

tter ‘

A’.”

Rea

d th

e fo

llow

ing

sequ

ence

of l

ette

rs: S

A V

E A

H A

A R

T

ERR

OR

S : N

o sq

ueez

e w

ith ‘A

’ & S

quee

ze o

n le

tter o

ther

than

‘A’

If u

nabl

e to

com

plet

e Le

tters

P

ictu

res

0 - 2

Er

rors

> 2

Erro

rs

NO

1. A

cute

Cha

nge

or F

luct

uatin

g C

ours

e of

Men

tal S

tatu

s:

Is th

ere

an a

cute

cha

nge

from

men

tal s

tatu

s ba

selin

e?

OR

Has

the

patie

nt’s

men

tal s

tatu

s flu

ctua

ted

durin

g th

e pa

st 2

4 ho

urs?

YES

Cop

yrig

ht ©

200

2, E

. Wes

ley

Ely

, MD

, MP

H a

nd V

ande

rbilt

Uni

vers

ity, a

ll rig

hts

rese

rved

• • ••

Con

fusi

on A

sses

smen

t Met

hod

for t

he IC

U (C

AM

-ICU

) ST

EPD

ELIR

IUM

ASS

ESSM

ENT

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

Upo

sitiv

eD

ELIR

IUM

Pre

sent

4. D

isor

gani

zed

Thin

king

:

1.

Will

a s

tone

floa

t on

wat

er?

2. A

re th

ere

fish

in th

e se

a?

3. D

oes

one

poun

d w

eigh

mor

e th

an tw

o?

4. C

an y

ou u

se a

ham

mer

to p

ound

a n

ail?

Com

man

d: “

Hol

dup

this

man

y fin

gers

” (H

old

up 2

fing

ers)

“N

ow d

o th

e sa

me

thin

g w

ith th

e ot

her h

and”

(Do

not d

emon

stra

te)

OR

Add

one

mor

e fin

ger”

(If p

atie

nt u

nabl

e to

mov

e bo

th a

rms)

0 - 1

Erro

r

> 1

Erro

r

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

3. A

ltere

d Le

vel o

f Con

scio

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rent

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thin

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sed

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sess

men

t in

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1)

RA

SS o

ther

th

an z

ero

RA

SS =

zer

o

2. In

atte

ntio

n:

“Squ

eeze

my

hand

whe

n I s

ay th

e le

tter ‘

A’.”

Rea

d th

e fo

llow

ing

sequ

ence

of l

ette

rs: S

A V

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H A

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T

ERR

OR

S : N

o sq

ueez

e w

ith ‘A

’ & S

quee

ze o

n le

tter o

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than

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nabl

e to

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plet

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tters

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ictu

res

0 - 2

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rors

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rs

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1. A

cute

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nge

or F

luct

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e of

Men

tal S

tatu

s:

Is th

ere

an a

cute

cha

nge

from

men

tal s

tatu

s ba

selin

e?

OR

Has

the

patie

nt’s

men

tal s

tatu

s flu

ctua

ted

durin

g th

e pa

st 2

4 ho

urs?

YES

Cop

yrig

ht ©

200

2, E

. Wes

ley

Ely

, MD

, MP

H a

nd V

ande

rbilt

Uni

vers

ity, a

ll rig

hts

rese

rved

• • ••

Con

fusi

on A

sses

smen

t Met

hod

for t

he IC

U (C

AM

-ICU

) ST

EPD

ELIR

IUM

ASS

ESSM

ENT

CA

M-IC

U n

egat

ive

NO

DEL

IRIU

M

CA

M-IC

Upo

sitiv

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ELIR

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Pre

sent

4. D

isor

gani

zed

Thin

king

:

1.

Will

a s

tone

floa

t on

wat

er?

2. A

re th

ere

fish

in th

e se

a?

3. D

oes

one

poun

d w

eigh

mor

e th

an tw

o?

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an y

ou u

se a

ham

mer

to p

ound

a n

ail?

Com

man

d: “

Hol

dup

this

man

y fin

gers

” (H

old

up 2

fing

ers)

“N

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me

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g w

ith th

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and”

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te)

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one

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atie

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mov

e bo

th a

rms)

0 - 1

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r

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CA

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M

CA

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U n

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NO

DEL

IRIU

M

3. A

ltere

d Le

vel o

f Con

scio

usne

ss

Cur

rent

RA

SS le

vel (

thin

k ba

ck to

sed

atio

n as

sess

men

t in

Step

1)

RA

SS o

ther

th

an z

ero

RA

SS =

zer

o

2. In

atte

ntio

n:

“Squ

eeze

my

hand

whe

n I s

ay th

e le

tter ‘

A’.”

Rea

d th

e fo

llow

ing

sequ

ence

of l

ette

rs: S

A V

E A

H A

A R

T

ERR

OR

S : N

o sq

ueez

e w

ith ‘A

’ & S

quee

ze o

n le

tter o

ther

than

‘A’

If u

nabl

e to

com

plet

e Le

tters

P

ictu

res

0 - 2

Er

rors

> 2

Erro

rs

NO

1. A

cute

Cha

nge

or F

luct

uatin

g C

ours

e of

Men

tal S

tatu

s:

Is th

ere

an a

cute

cha

nge

from

men

tal s

tatu

s ba

selin

e?

OR

Has

the

patie

nt’s

men

tal s

tatu

s flu

ctua

ted

durin

g th

e pa

st 2

4 ho

urs?

YES

Cop

yrig

ht ©

200

2, E

. Wes

ley

Ely

, MD

, MP

H a

nd V

ande

rbilt

Uni

vers

ity, a

ll rig

hts

rese

rved

• • ••