RASS Scale Scores Overview

A patient who shows little movement with eye opening but no eye contact in response to voice.

An unarousable patient who doesn't respond to voice or physical stimulation.

A patient who is calm and alert, showing no signs of agitation or sedation.

A patient who is drowsy but can sustain awakening for more than 10 seconds.

A restless patient who is anxious but not aggressive or vigorous in movements.

A patient who is mildly sedated and only awakens briefly with eye contact to voice for less than 10 seconds.

A patient who is agitated, showing frequent nonpurposeful movement.

A very agitated patient who may try to remove tubes or catheters and exhibit aggressive behavior.

A combative patient, possibly dangerous and requiring immediate intervention.

A patient who shows movement or eye opening in response to physical stimulation, but cannot respond to voice.

A tool used to measure the level of agitation or sedation in ICU patients.

The RASS measures the level of agitation or sedation in ICU patients.

A patient with a RASS score of +4 is combative.

A patient with a RASS score of +3 is very agitated and may exhibit aggressive behaviour.

A patient with a RASS score of +2 is agitated, showing frequent nonpurposeful movement and may fight the ventilator.