RASS HELP
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This app is intended to help students learn the descriptors of the Richmond Agitation-Sedation Scale (RASS). RASS is a medical scale used to measure the agitation or sedation level of a person.
The criteria are:
Score | Term |
+4 | Overtly combative or violent; immediate danger to staff |
+3 | Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff |
+2 | Frequent non-purposeful movement or patient-ventilator dyssynchrony* |
+1 | Anxious or apprehensive but movements not aggressive or vigorous |
0 | Spontaneously pays attention to caregiver |
-1 | Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice |
-2 | Briefly (less than 10 seconds) awakens with eye contact to voice |
-3 | Any movement (but no eye contact) to voice |
-4 | No response to voice, but any movement to physical stimulation |
-5 | No response to voice or physical stimulation |
*According to the (US) National Institute of Health, ventilator dyssynchrony is defined as the inappropriate timing and delivery of a mechanical breath in response to patient effort. It may cause ventilator-induced lung injury (VILI).
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