Richmond Agitation–Sedation Scale

Score

Term

Description

+4 Combative 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 only — Full Text
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