About RASS

Richmond Agitation-Sedation Scale (RASS) Nurses General Nursing


My colleague and I have encountered patients who are able to open their eyes on their own, engage in activities that might not be fully conscious, and seem to follow their own routine(sleep and awake), yet they do not respond to voice. It appears as though they are living in their own little world, disconnected from external engagement. The challenge we face is determining the appropriate RASS score for such patients. Would they be classified as -3, indicating a lack of eye contact, or as 0, which suggests a patient is alert and oriented? We have this argument cause none of us were trained for RASS accuracy. Help someone could help us to clarify.

I'm not sure what the rational for  documenting a RASS score for all patients is but both my current and last facility required this once a shift for all patients, regardless whether they were receiving sedation or not.  

However, if your facility is going to require this, as with the Glasgow Coma Score, the patient should be scored based on their best response.  

Specializes in Critical Care, Procedural, Care Coordination, LNC.

I would say this is not a RASS of 0; a score of -3 seems appropriate, but I'd need to complete the assessment to be sure. In the ICU RASS assessment, eye contact is crucial. If the patient doesn't respond to your voice with eye contact, they're not alert. Just being awake doesn't mean they're alert; thus, no eye contact in response to voice or stimulation indicates at least a RASS score of -3.

Do you conduct CAM ICU Delirium evaluations? This might also explain the lack of eye contact. In CAM ICU + patients, being awake but lacking alertness is a common sign of delirium.

I hope this clarifies things!

Also, I would consider bringing this to my unit manager, as it is not appropriate to have staff documenting something they do not understand -- advocate for the education you, all the nurses, and the patients deserve, as it is not serving anyone to be documenting something we don't even understand and that is a failure on your educators and/or managers part - not yours. 

Thank you for your responses. I work in the MICU, but since no one has received proper education on RASS, it's easy for us to get confused or for our evaluation to be influenced by the patient's level of consciousness. I would greatly appreciate any past experiences with RASS that you could share! We are currently hoping to promote correct assessment by nurses, but as we are not in an English-speaking country, we are still figuring things out together! Anyway, thank you all for addressing my question.

Specializes in Serious Illness, EOL, Death Care, Final Dispo.

RASS  0 is alert and calm, they're aware of the environment and able to interact, it's a chill baseline - like a dog sitting upright looking around quietly

-1 is drowsy, they're dozing but easily roused to eyes open and able to interact for more than 10 seconds, like a dog snoozing in the sun who wakes up when you call him, eats a snack, enjoys a few scritches then goes back to snooze

- 2 lightly sedated, able to open eyes somewhat and respond to simple commands like 'grab the side rail we're turning you over' after you've been given versed and fentanyl for a colonoscopy

- 3 moderately sedated, raises eyebrows or other vague response to voice but not much more than that, which sounds like the patient in the post

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