Overtly combative or violent; immediate danger
to staff
+3
Very agitated
Pulls on or removes tube(s) or catheter(s) or has
aggressive behavior
toward staff
Frequent non purposeful movement or patient–ventilator
dyssynchrony
+1
Restless
Anxious or apprehensive but movements not aggressive
or vigorous
0
Alert and calm
-1
Drowsy
Not fully alert, but has sustained (more than
10 seconds) awakening,
with eye contact, to voice
-2
Light sedation
Briefly (less than 10 seconds) awakens with
eye contact to voice
-3
Moderate sedation
Any movement (but no eye contact) to voice
-4
Deep sedation
No response to voice, but any movement to physical
stimulation
-5
Unrousable
No response to voice or physical stimulation
Procedure
1. Observe patient. Is patient alert and calm (score
0)?
Does patient have behavior that is consistent with
restlessness or agitation (score +1 to +4 using the criteria listed above,
under DESCRIPTION)?
2. If patient is not alert, in a loud speaking
voice state patient's name and direct patient to open eyes and look at
speaker. Repeat once if necessary. Can prompt patient to continue looking
at speaker.
Patient has eye opening and eye contact, which
is sustained for more than 10 seconds (score -1).
Patient has eye opening and eye contact, but this
is not sustained for 10 seconds (score -2).
Patient has any movement in response to voice,
excluding eye contact (score -3).
3. If patient does not respond to voice, physically
stimulate patient by shaking shoulder and then rubbing sternum if there
is no response to shaking shoulder.
Patient has any movement to physical stimulation
(score -4).
Patient has no response to voice or physical stimulation
(score -5).
Source: Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane
KA, Tesoro EP, Elswick RK. The Richmond Agitation-Sedation Scale: validity
and reliability in adult intensive care unit patients. Am J Respir Crit
Care Med. 2002 Nov 15;166(10):1338-44. Table
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