Index
Module 17 • PADIS
Pain, Agitation/Sedation, Delirium, Immobility & Sleep
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Data Tables
Pain, Agitation/Sedation, Delirium, Immobility & Sleep
Joanna L. Stollings ~3 min read Module 17 of 20
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Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Table 5. Richmond Agitation-Sedation Scale (RASS) (continued)

Score

Term

Description

Procedure

1

Observe patient. Is patient alert and calm (score 0)? Does patient have behavior that is consistent with rest-

lessness or agitation (score +1 to +4 using the criteria listed above, under Description)?

2If patient is not alert, in a loud speaking voice, state the patient’s name and direct the 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 βˆ’1). Patient has eye opening

and eye contact, but this is not sustained for 10 seconds (score βˆ’2). Patient has any movement in response to

voice, excluding eye contact (score βˆ’3).

3

If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing ster-

num if there is no response to shaking shoulder. Patient has any movement to physical stimulation (score

βˆ’4). Patient has no response to voice or physical stimulation (score βˆ’5).

Reprinted with permission from: American Thoracic Society. Copyright Β© 2014 American Thoracic Society. Sessler CN, Gosnell M, Grap MJ, et al. The Richmond

Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002;166:1338-44. Official Journal of the American

Thoracic Society.

Table 6. Riker Sedation-Agitation Scale

Dangerous agitation

Pulling at ETT, trying to remove catheters, climbing over bedrail, striking at

staff, thrashing side to side

Very agitated

Does not calm despite frequent verbal reminding of limits, requires physical

restraints, biting ETT

Agitated

Anxious or mildly agitated, trying to sit up, calms down to verbal instructions

Calm and cooperative

Calm, awakens easily, follows commands

Sedated

Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off

again, follows simple commands

Very sedated

Arouses to physical stimuli but does not communicate or follow commands,

may move spontaneously

Unarousable

Minimal or no response to noxious stimuli, does not communicate or follow

commands

ETT = endotracheal tube.

Adapted with copyright permission from: Lippincott Williams and Wilkins/Wolters Kluwer Health. Simmons LE, Riker RR, Prato BS, et al. Assessing sedation during

intensive care unit mechanical ventilation with the Bispectral Index and the Sedation Agitation Scale. Crit Care Med 1999;27:1499-504.
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