ARCHETYPE Richmond agitation sedation scale (RASS) (openEHR-EHR-OBSERVATION.richmond_agitation_sedation_scale.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.richmond_agitation_sedation_scale.v0
ConceptRichmond agitation sedation scale (RASS)
DescriptionA scale used to measure the agitation or sedation level of a patient.
UseRASS is mostly used in the setting of mechanically ventilated patients in the intensive care unit to avoid over- and under-sedation. Also as the first step in administering the Confusion Assessment Method in the ICU (CAM-ICU), a tool to detect delirium in intensive care unit patients.
PurposeTo measure the agitation or sedation level of a hospitalized patients.
ReferencesSessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation–Sedation Scale. American Journal of Respiratory and Critical Care Medicine, 166(10): 1338-1344, 2002.
Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289(22):2983-91, 2003.
Copyright© openEHR Foundation
AuthorsAuthor name: Alan D. March
Organisation: Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
Email: alandmarch@gmail.com
Date originally authored: 2016-08-31
Other Details LanguageAuthor name: Alan D. March
Organisation: Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
Email: alandmarch@gmail.com
Date originally authored: 2016-08-31
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation–Sedation Scale. American Journal of Respiratory and Critical Care Medicine, 166(10): 1338-1344, 2002. Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289(22):2983-91, 2003., current_contact=Alan D. March , original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=F6D949667A98B43C75E240D5AB9DC9F4, build_uid=beec928f-e28b-4add-bdaf-98a2b8f35fbd, revision=0.0.1-alpha}
KeywordsRichmond Agitation Sedation Scale, RASS, scale, agitation, sedation, mechanical ventilation, intensive care unit
Lifecyclein_development
UIDe4592dc5-fab8-43f6-93c5-cc635d80ed84
Language useden
Citeable Identifier1013.1.2606
Revision Number0.0.1-alpha
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-4: Deep sedation [Patient has any movement to physical stimulation.]
-3: Moderate sedation [Patient has any movement in response to voice, excluding eye contact.]
-2: Light sedation [Patient has eye opening and eye contact, but this is not sustained for 10 seconds.]
-1: Drowsy [Patient has eye opening and eye contact, which is sustained for more than 10 seconds.]
0: Alert and calm [Spontaneously pays attention to caregiver]
1: Restless [ Anxious or apprehensive but movements not aggressive or vigorous.]
2: Agitated [Frequent nonpurposeful movement or patient–ventilator dyssynchrony.]
3: Very agitated [Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff.]
4: Combative [ Overtly combative or violent; immediate danger to staff.]
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-4: Deep sedation [Patient has any movement to physical stimulation.]
-3: Moderate sedation [Patient has any movement in response to voice, excluding eye contact.]
-2: Light sedation [Patient has eye opening and eye contact, but this is not sustained for 10 seconds.]
-1: Drowsy [Patient has eye opening and eye contact, which is sustained for more than 10 seconds.]
0: Alert and calm [Spontaneously pays attention to caregiver]
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