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1、ProcedureforRASSAssessment
1..Observepatient
• Patientisalert,restless,oragitated.
2. Ifnotalert,statepatent'snameandsaytoopeneyesandlookatspeake匚
* Patientawakenswithsustainedeyeopeningandeyecontact.
* Patientawakensvatheyecpeningandeyecontact,butnotsustained.
* Patienthasanymovementinrespons
2、etovoicebutnoeyeocntact.
3. Whennoresponsetoverbalstimulation,physicallystimulatepatientbyshakingshoulderand/orrubbingsternum.
• Patienthasanymovementtophysicalstimulation.
• Patienthasno'responsetoanystimulation-
Socre0to-b4
Socre-1
Soore-2
Socre-3
Socre-4
Socre-5
Table1.TheRichmondAgit
3、ation-SedationScale(RASS)
Score
Term
Description
+4
Combative
Overtlycombative,violent,innmediatedangertostaff
+3
Veryagitated
Pullsorremovestube(s)orcatheterfs)；aggressive
+2
Agitated
FrequentnonpurposeLImovement,fightsventilator
+1
Restless
Anxiousbutmcvementsnotaggressivecfvi
4、gorous
0
Alertandcalm
-1
Drowsy
Notiullyalert,buthassustainedawakening
(eyeopenirig/eyecontact)tovoice{>10seconds)
-2
Lightsedation
Brieflyawakerkswitheyecontacttovoice(<10seconds)
Verbal
stimulation
-3
Moderatesedation
Movementoreyeopeningtovoice(butnoeyecontact)
-4
Deepse
5、dation
Noresponsetovoice,butmovementoreyeopeningtophysicalstimjlatkr
Physicalstimulation
-5
Unarajsable
Noresponsetovaioeorptiysicalstimulation
Adaptedwithpemission.^
RASS镇静程度评估表(RichmondAgitation-SedationScale)
+4
有攻击性
有暴力行为
+3
非常躁动
试着拔出呼吸管，胃管或静脉点滴
+2
躁动焦虑
身体激烈移动，无法配合呼吸机
+1
不安焦虑
焦虑紧张但身体只有轻微的移动
0
清醒平静
清醒自然状态
-1
昏昏欲睡
没有完全清醒，但可保持清醒超过十秒
-2
轻度镇静
无法维持清醒超过十秒
-3
中度镇静
对声首有反应
-4
重度镇静
对身体刺激有反应
-5
昏迷
对声音及身体刺激都无反应
RASS镇静评分
