Getting the Richmond Agitation-Sedation Score (RASS) Right: How to Assess and Why It Matters

[00:00:00] Annie VO: As progressive and critical care nurses, we are required to assess and chart our patients sedation levels. And while there are many ways to assess sedation, the Richmond agitation, sedation scale, AKA RAs. Is the most widely adopted, especially in the critical care setting.

The RAs is a 10 point scale ranging from plus four, four combative agitation down to. Minus five for a patient who is unresponsive to nauseous. Simuli. And this is an important tool because it gets us all on the same page. When talking about sedation. We can all communicate clearly about a patient's level of sedation. So as to achieve all the good things like decreased ventilator time and decreased delirium.

I was recently part of a transition and practice program for nurses who are transitioning from acute care to the ICU. And well, I've actually used RAs as a progressive care nurse. It's important really came into focus. When I started managing critically ill patients.

Who were intubated and on sedative trips.

So the craziest thing happened. I went to chart my patients' sedation scores, but found that they differed wildly from the nurses who tried it before me. And to be honest, I was getting a lot of minus threes and minus fours, which wasn't good because the nurses before me were charting minus ones and minus twos. And the parameters from my trips were. You guessed it to maintain a patient at arrest. Zero to negative two. So this put me in such an awkward spot. And as a new to critical care nurse, I didn't want to rock the boat. But at the same time from hosting this podcast. I knew the grave dangers of over sedation and delirium. And that we were setting our patients up for terrible outcomes.

If we continued to allow our patients to maintain such deep levels of sedation.

So, what did I do? I phoned a friend. I called up Kaley Dayton, who is a critical care nurse practitioner and my go-to person for all things, early mobility, delirium prevention, and ICU liberation. Kaylie. And I recorded our conversation about some of my burning questions as a newbie in the ICU. And this episode will cover what nurses need to know about RAs. Why it's important and how to accurately score our patient's agitation or sedation levels. No more guessing here, because by the end of this episode, you will feel confident in your RAs assessment. And have some added insight for how to use this score to promote better outcomes. The second part of our discussion, I will save for next week's episode, which will be about spontaneous awakening trials. Stay tuned.

[00:03:09] Kali: I'm a nurse practitioner. , I started my career as a nurse. 14 years ago in an awake and walking ICU where almost all patients were allowed to wake up after intubation and mobilize shortly after it's a high acuity medical surgical ICU. It had one of the highest COVID units during the pandemic, and most patients really were even during COVID awake and walking in their rooms while intubated on ventilators, even on high settings.

So that was my experience for the first two years of my career. And then I became a travel nurse and I was. I was very shocked to find a completely different practice in the 11 other ICUs I worked in where patients were automatically sedated upon intubation, no matter the reason they were intubated.

I started to ask questions and I was treated like I was insane. So I ended up just going with what the normal practices were. After those few years, I returned back to that awake and walking ICU during grad school and really started to dissect why there was such a huge contrast in practices, but especially Outcomes.

Why were most of my patients successfully extubating and walking out the doors and going home when The previous two years during travel nursing, most of my patients ended up with tracheostomies and had very different outcomes and they were harder to take care of and not nearly as fun. So this exploration led me to really dive into the ABCDF bundle, the research behind delirium mobility.

And that led me to now be a consultant. I helped teams master the ABCDF bundle.

And become awake in walking ICUs?

[00:04:35] Annie: As I mentioned earlier, Kaylee, I'm, I'm new to the ICU. I do come with eight years of experience in, med surg, tele, , intermediate care. But two things have come up , for me that have been confusing. And, you know, I always think if it's confusing for me, it's probably confusing for other nurses too.

I was wondering if you could speak about the RAS score, , which is a measurement of agitation, . And, you know, I was actually using it in, , acute and intermediate care as well. But it's kind of taken on this whole new significance in the ICU.

It's something we're assessing every few hours. And I've, I found that, there's not much consistency in, in nurses, assessing RAS.

If you, if you had the chance to go in front of a classroom of nurses and, and give your spiel on how to do a good RAS assessment, like, I would love to hear what you have to say.

[00:05:26] Kali: Absolutely. And anytime we teach the how to something, we should preface with the why. So Richmond agitation sedation scale is to measure psychomotor activity. It is how arousable they are or how sedated they are, right? What we culturally have perceived the RAS to be is an anxiety scale. Now, obviously, certain psychomotor activities can be rooted in anxiety, it can reveal anxiety, it can be a symptom of anxiety. But because we've believed it to be an anxiety scale, that's influenced how we sedate patients. For example, we've believed that if a patient is not moving, they're not having anxiety. So if we sedate a patient, we've treated their anxiety. When you talk to survivors, they were still writhing in delirium under sedation.

They were still terrified and confused. They were still aware of their environment of the endotracheal tube. They still had pain. They were still in there and they were so anxious. They were just chemically restrained and unable to express their anxiety. So it's really important to understand what's happening to the patient when they have a low RAS score. Or recognize that we don't know what's happening to the patient. We don't know what they're experiencing, but what we do know is that just because they have a low RAS score, just because they're not showing their anxiety does not mean that they do not have anxiety or agitation fear, confusion and especially pain.

So this is why it's really important to have a. Good grasp on the RAS because how we sedate patients greatly impacts their outcomes. So a zero on the RAS score should be most of our goals for most patients.

[00:07:27] Annie: intubated patients.

[00:07:29] Kali: Yes, intubated, yeah. So again, zooming out, we're talking about ICU liberation. ICU liberation is the pathway to implement the ABCDEF bundle.

And the very goal of the bundle is to have patients that are more Awake, cognitively engaged, and physically active to have the ability to express their unmet physical, emotional, and spiritual needs. So you want them awake, autonomous, engaged, moving, communicative. Now, if patient's a negative 2, can they really write on a whiteboard? Can they text with their phones?

Can they use the call light? Can they tell you what they need? Right? So, a negative 1 on the RAS score is when they respond to voice. You don't have to touch them. You just say, Hi Betty, and they open their eyes for more than 10 seconds. And then maybe drift off. Zero is obviously when they're spontaneously awake and they're just chilling there in bed, right?

Or in the chair, wherever they are. But negative one is when they keep their eyes open for over 10 seconds. Negative two is when they keep their, they open their eyes to voice, but they close them. After before 10 seconds are up. Negative three is when you talk to them and they may be like raise their eyebrows and maybe open their eyes, but they don't make eye contact. So negative one negative two is light sedation. Negative three is moderate sedation. Some studies consider still negative three to be deep sedation. Negative four is when you have to touch them to get them to respond. And that response can be a flinch. It can be eye opening. Negative five is when they do not respond To noxious stimuli so you can give them a sternal rub and they still don't open their eyes. What I've seen as a consultant when I go and train teams is that even our seasoned nurses. But the best of intentions and all the expertise and so many things when they go to assess a RAS, and I relate to this cause I did this as well. When you approach a patient, especially to introduce yourself you are touching them and you're saying, hi, I'm your nurse.

So caring and compassionate. You're connecting with your patient, right? But when you do that. And assess a RAS off of that, you're missing a big piece. Just because you touch them and they open their eyes or kind of moved in response does not mean that they're a negative two or negative one. It means that you don't know where they're at.

You should first, when you're assessing a RAS, approach them and just use voice. Stand there, do not touch them, and say, Hi, John. John, are you there? And then see how they respond, how long they keep their eyes open. Just because they open their eyes and you, and you turn your back to go grab a med or something, does not mean that you know how long they kept their eyes open for. , and then if they're not responding to voice, then you need to do touch and see how much touch they need or do they respond to touch. Now this is so important because deep sedation, which is again, negative four, negative five. Some studies it's a negative three. That is an independent predictor of mortality. If patients do not respond to voice, they are twice as likely to die. It's an independent risk factor and predictor of delirium, which we talked about in our previous episodes that delirium is acute brain failure. It's an organ failure. Delirium doubles the risk of dying in the hospital. It makes patients 120 times greater, have a greater risk of having long term cognitive impairments or a post ICU dementia.

So, Our goal should rarely be to have patients unresponsive to voice. Sometimes that might be necessary. If they have seizures, if they, , have intracranial hypertension, if they cannot oxygenate with movement, if they're prone to paralyzed, then you go to negative four, negative five, right? But recognize that it comes at a price and we should, that doesn't mean that that patient doesn't isn't appropriate for the bundle.

It just means that they're at a different cost. Exception and different criteria at that time, we should still be looking at the bundle saying, okay, what's the rest? What's their CAM score? We can't check right now, but we're gonna be thinking about that because we wanna look at why are they sedated? Why are they so deeply sedated?

Do we still have that need for sedation? So we need to be talking to each other. An RN report saying their RAS of negative two, they open their eyes to voice for over 10 seconds, maybe even specifying that so that when the next nurse comes in and now they require touch, has something changed? We should be worried about that.

Do they have a stroke? Are they developing delirium, that should be a warning sign of some change if the rate in the, on the pump didn't change. And now the nurse sees something different than what they received in report. We need to be investigating, okay, has that propofol accumulated in the adipose tissue? But if we don't do an accurate RAS, and then we don't titrate our sedation to that RAS, we're one, setting patients up for worse outcomes, right? An organ failure, even death, longer time in the ventilator, longer time in the ICU, more ICU acquired weakness, more work for the team. So it might be perceived as easier to keep them deeply sedated.

It's not. Delirium can increase their time in the ICU by at least 4. 77 days. Also, if you as a nurse, are sedating a patient to a RAS lower than what is prescribed. So a lot of our sedation orders have a sedate to a RAS of negative one, negative two. maybe the family finds out what a RAS score is and they know what the RAS score should be.

Now they see that the patient is actually negative four, negative five. That's a liability for the nurse. That is giving more medication than prescribed. You would never give an extra gram of vancomycin. But when we sedate past a prescribed RAS score, we're giving more medication than prescribed that's outside the scope of practice for an RN.

And it may be considered, you know, malpractice. I hate, you know, using that word, but we need to be aware because we need to protect ourselves, right? So if patients have worse outcomes and we see, for example, nurse charts negative two, but we see physician charts. That the patient, was unarousable, or physical therapy comes into work with the patient and they say they were unarousable to voice. For, for me, I've done medical reviews and that braids a bunch of red flags. Someone's not charting accurately here. Something's wrong. If the patient was not able to engage in physical therapy because they were too sedated. Something happened if that that sedation order was for zero to negative one, but now they're negative three, it's really hard for them to engage with physical therapy, but they're not charred as a negative three.

Like, there, there are so many liabilities when, within that. So it's really important. And then on the flip side, so you've got We talked about the negative side of RAS, the sedated side. It's important to understand the positive sides too. So RASA plus one is when they're fidgety, kind of restless. Negative two is when they're getting like more movement.

Maybe they're banging on the side rails. They're like slamming their hands or their. Legs on the bed, right? That's, that's restless. Some studies show plus two and up is agitation. Some studies say just plus three and plus four is agitation. But sometimes we use the word agitation to describe when they're uncomfortable, when they're anxious.

That doesn't mean that they're agitated. Agitated is when they're doing more, more psychomotor activity. So dangerous behavior is when you enter into a plus three, which is when they're trying to pull out their lines or their tubes. That's plus three. That's what we're worried about, right? That's dangerous behavior.

Plus four is when they're trying to cause harm to themselves or to the clinicians. So that's why we see delirium increases workplace violence because you get so much confusion and agitation from the delirium and then that's when they lash out.

They're confused and they're agitated, they're scared because they think you're trying to kidnap them. That's why they hit clinicians, right? So when it comes to sedation, an indication for sedation in that sense would be a RAS of plus three or plus four when they're having, they're at risk of hurting themselves with lining tube removals or hurting clinicians, right?

That's when you use sedation to do some chemical restraint, but then we need to be looking at what's the RAS goal with that. Do we want to sedate them so that they can't mobilize, or do we want to sedate them to the point of being a RAS of zero? I'm okay with a plus one, so that they can then mobilize.

Can we use some light, light sedation to get them safe enough to then treat the cause of that agitation? So yes, obviously when they're arrasive plus one plus two, you're seeing signs of a lot of things. Just because they're moving doesn't mean that they're uncomfortable. They could be scared, confused, they could, but arrasive plus one or plus two, ask them, talk to them.

What happens right now is that we are so trained. To perceive patients as being asleep and comfortable when they're at a low RAS that we assume that if they're at a higher RAS that it's just the endotracheal tube, but we can't alter that at the moment, so we better make them comfortable and put them back down to a lower RAS.

And if we don't see those signs of discomfort, And, and anxiety and even agitation, we've fixed the problem. It's better to be quote sleeping than to be aware of the endotracheal tube. Now, coming from an awake and walking ICU, most of my patients were a RAS of zero,

[00:17:21] Annie: Wow.

[00:17:21] Kali: negative one, if they're sleeping or if they are a little bit delirious, sometimes if they're a plus one, plus two.

We use that momentum to mobilize them. We don't just sedate them for that, but it's not until they really got crazy and dangerous that we then used sedation to keep them, everyone safe, but we never sedated them. Beyond being able to mobilize them, be not, we didn't want to take away their ability to communicate.

We couldn't treat the underlying cause. So sometimes, you'd be surprised and amazed what patients tell you when you give them a pen and paper. If you don't automatically run back to sedation when you see some restlessness, some discomfort, give them pen and paper, said what, what do you need? What are you, are you in pain?

What do you need? Okay, sometimes they'll ask, I, I need to poop.

[00:18:06] Annie: hmm.

[00:18:07] Kali: That's what's causing it. Now, was sedation gonna fix that? Sometimes they'll say, where is my child?

[00:18:13] Annie: Mm hmm.

[00:18:14] Kali: They're panicked being like, I don't know where I'm at. And I may be in their delirium. They thought something was happening to their kids.

You don't know what those questions are. I remember one patient had muscular dystrophy and she just barely right with her, her hand and she had aspiration pneumonia and while she was intubated and she was really worried because the father, her child was not a safe person. And if she wasn't there, was he going to get custody?

And there was this whole battle with all the legalities, she was able to navigate that and tell us what she needed and what was going on and how to keep her and what instructions to give her family and her anxiety immediately decreased. So sedation never would have fixed that.

It would have worsened it because she would probably be more concerned and more confused. Right? So. When there are breaths of plus one plus two, that doesn't mean you need to run back to sedation. It means you got to figure out what's going on. If it's pain, treat it, then reevaluate. Therapy communication, I think sometimes is scoffed at in the ICU because we're like, it's life or death.

We don't have time for that. No, this could be life or death for them.

So one patient said one time that they had chest pain. So they were uncomfortable from the chest pain, but because the nurse gave him pen and paper, they were able to relay that they got a chest x ray. The patient had a large pneumothorax right as they were looking at that image on the machine outside the room with the patient coded.

They knew exactly what had caused it. They were able to intervene while they were coding and got the patient back. That not sedating him because he was RAS of plus one or plus two saved his life.

So this is why it's really important to understand RAS. When we use the word agitated. And we relay that in rounds, or especially in report.

We say the patient was agitated, but we don't ask, well, why were they agitated? Or, or what was their arrest? I want to understand, are they dangerous? Do I need to protect myself, right? When I do an awakening trial, do I need to know, were they trying to punch you? Or were they shifting in bed and showing discomfort?

Because I can, I can deal with that. Like, I can investigate, we can work with that, right? But do I need, I need to know how dangerous this is when I go to approach an awakening trial. Do I need to have physical and occupational therapy with me? Because they were so delirious during that awakening trial that now we need to treat delirium?

But we're not asking questions. We're like, oh yeah, they're agitated. Yeah, I'm not going to touch that sedation.

So here's an example. I was working with a team a few weeks ago. There's a patient that had overdose on fentanyl and Xanax, and he had gross aspiration, pneumonia. And he was a large obese man. So I walk in to just even just tour the unit to do gap analysis and I'm seeing that his propofol is at 50 mics and I'm asking questions and they said, well, he was really agitated last night. So he'd come in the day before, I think probably afternoon, had worsening respiratory distress, was intubated overnight.

And he was coming out thrashing. And so they were really scared. They heard from the night shift that he was thrashing and he's a big guy, poly substance abuse, right? You've got all these labels going on and you don't want to put clinicians at risk, right? Also, he was on a peep of 16 and a hundred percent.

So he's got sick lungs, right? So we're worried about his lungs. We're worried about his safety. We can't handle his thrashing, right? But I also looked at a different perspective. He's got sick lungs. He's got aspiration pneumonia. A bronchoscopy is only going to get so deep into the lungs. He needs pulmonary toileting.

He needs to sit up. Also, he's obese. He's got a large abdomen. Is his peep ever going to go down with the abdomen, with the pressure from his abdomen? So if we're sedating for a ventilator setting. That sedation is never going to come off. Also, will his ventilator resettings really lower if we let that aspiration just sit in his lungs?

What if we sat him up, relieved the pressure on his abdomen, let his lungs inflate, let him cough, let him mobilize that vomit in his lungs. Would that help? Next question was, why is he thrashing? Is he delirious? Well, he was just intubated overnight. Yes, he's getting propofol, but that's a short amount of time to have it. But look at his history. He's a posi He's, he's addicted and we didn't know exactly to what. He's, we knew he was a fentanyl user, but also benzodiazepines maybe, so is he withdrawing? He overdosed, but they probably gave him Narcan. They reversed it. So now is he withdrawing? So, I pitched this to the team. I thought I was insane, but they went for it because that's what I was there for to show them new tricks.

Right? So we started oxycodone down the feeding tube. Clonopin down the feeding tube to cover for his withdrawal. I didn't want them taking sedation off until we knew that he was not going to be withdrawing because there's nothing you can do with that. You can't have him be a RAS of plus three plus four, right?

Not safe. And he's at high risk of self extubating when he's withdrawing, right? So we covered that. Now, remember his propofol is still going at 50, but I was nervous to like mess, take that off until we had coverage for his withdrawal, right? A few hours later they, I have him take it off. He doesn't respond.

He's a RAS of negative five. Now I asked, what is his RAS order for? And it was for negative three. They didn't reevaluate that. They didn't necessarily change anything because they'd gotten from report that he was thrashing and they were scared. But if I hadn't been there, he wouldn't even even had an awakening trial for another like, 18 hours. He's obese. That propofol at higher rates was just settling into his adipose tissue. So it took him six hours to metabolize that out. Now, if I had run for another few days at that rate, which it likely would have been, he was also getting versed drips on top of it. He would have been so delirious, so deconditioned.

That was another concern. They're like, well, we want to keep the staff safe. But my question was how safe is it for a staff to move a 350 pound flaccid body? He was walking yesterday or at least the night before, right? He was in a motel, but he was independently moving. We want to preserve that physical function.

Not just for him, but for the staff. And also, he's probably going to be on the ventilator for a while because his lungs are so sick right now. He's at higher risk of developing ARDS. From the aspiration pneumonia. Like, we do not want to set him up to have a tracheostomy. He's already got, obviously, psychosocial problems at baseline.

He doesn't need a sedation to reduce brain injury. More trauma on baseline. We don't know why he's self medicating, right? So, just look at this whole picture of, is that RAS really safe for him? That's going to double his risk of dying, if the order is for negative three, which I would like to see more of a negative two, negative one, right, for him, and then eventually be a zero.

But if that's, if that's really the order, is that within your scope to have him at a negative five right now? And now, here's the thing, maybe it was a negative five, a negative three overnight, but it accumulated. So then it was negative five, but because there wasn't accurate RAS assessment being done, they're just looking at him and like, well, his eyes are closed, he's probably negative three. Or in probably negative two, it wasn't accurate documentation. It was outside their scope. It was putting the patient at more risk. It set him up to, because we brought in physical and occupational therapy when we took in that sedation, thinking, okay, maybe he'll wake up right away. So that wasted the PT and OT's time.

That took away an opportunity to mobilize the patient that they could have used. And they could have set him up for a much easier night because that they've mobilized him and helped him acclimate to the tube and made him comfortable and treated the anxiety he was having. Their night would have been different.

But what instead happened was. Day shift gets off. The patient's still metabolizing that propofols. It's off, but he's not doing anything. Night shift comes on. Now, what, 11, 12 o'clock at night? He comes out thrashing. Now, I don't think he was a full RAS of plus 3 or plus 4. I think he was a RAS of plus 2. He was banging on the side rails.

So not dangerous, but stressful, right? It's really stressful to have a patient look uncomfortable. They don't know what to do. They're not used to it, right? They're used to their patients being sedated. He's wanting to write. They don't even have a pen and paper in the room, you know, just lots of difficult things happen.

So they end up giving Versedrips overnight, or pushes overnight, which was not, that goes against the ADF bundle. You don't want to be giving benzodiazepines, but they were, I don't know why they didn't do Prostatex, would have been my preference. Point is, come in the morning and he's like a Rassiv plus one.

And so physical and occupational therapy can finally work with him. They sit him up. Oh, and at that point, he's saturating like 89, 90%, like kind of bouncing between the two while laying in their supine on high ventilator settings. So everyone's nervous, but there's nothing in the research that says that you can't mobilize patients in high ventilator settings.

As long as they're saturating, so it could have gone two ways. It could have, he could have de sat it upon setting up, but I was pretty confident because of what I've seen. Usually it goes up because their lungs can function better. So there's new studies coming out that being vertical, being upright has the same benefit to VQ mismatch as being supine.

So my thought was. Protein hand was going to be tricky. What if we got him up? Would we see the same benefit? And we did. He sat up and his saturation went up to 93, 94. And you could see the tension just released from his shoulders. He went from being super grumpy to Okay, give me a pen and paper, I can write, let's talk about this.

He got up to a chair. So that was on a Friday I left. He was up in a chair, awake they started to decrease his ventilator settings he was just kind of back between the bed and the chair, getting himself to the chair, wasn't, didn't need a ton of people, wasn't unsafe. By Monday he was extubated walking around the unit.

[00:27:49] Annie: Wow.

[00:27:50] Kali: Now the other option was to prone and paralyze him for his ventilator settings.

That would have taken him on a completely different course and would have been weeks on the ventilator. weeks and months in rehabilitation, it would just would have been a totally different story. But because we looked at what is his RAS, what's his goal, what's the cause of these, these symptoms that we're seeing, we were able to customize the care to keep him compliant with a bundle, which is awake, communicative, autonomous, mobile. That's why the RAS is so important. That's how we use

it.

[00:28:24] Annie: Do you, do you think that the nurses who were taking care of him were accurately measuring the RAF score

[00:28:32] Kali: No, and that's that's not on the nurses. I mean, it is. I mean, that's, that is a nurse's responsibility, right?

I also teach entire teams to do the RAS score. Cause I want everyone to be able to, to be. speaking the same language, but right now, usually only the nurses know the RAS scores, right? But this is a common problem throughout the entire community.

One study from Brazil showed that 70 percent of the patients were sedated beyond the RAS goal of zero to negative three, 70%. I had a nursing student go out and do a survey and The two ICUs where she was capstoning she found that, so she compared the prescribed RAS to the charted RAS to what she was observing. So she was going very literal. The RAS is supposed to be objective, right? But we've turned it into something subjective, right? So she looked at it very objectively, exactly like I described it, right?

[00:29:25] Kali: Do they open their eyes to voice? How long do their eyes stay open? Do they need touch? Do they respond? Right? So she found that 52 percent of patients were over sedated.

over half of the patients had inaccurate RAS scores and they were sedated past the prescribed RAS, which again is very dangerous. 38 percent were one point away from the target RAS goal. 62 percent were two points or more away from the target RAS goal. So their negative twos were usually Negative fours, or negative fives. And it's an independent predictor of mortality. So are we increasing mortality with doing inaccurate and inadequate RAS assessments?

Yes, absolutely. That's no one's intention. That's the reality

of it.

[00:30:16] Annie: And to clarify a point, a RAS score is independent of the use of sedatives, right? Like you can do an accurate RAS score on someone who is not on a sedative.

[00:30:28] Kali: Yep. We use it to guide sedation. But we should be doing on all of our patients. So when we have neurological changes, we need to be able to monitor that. So , you have maybe stroke patients that are like a little bit drowsy or they're delirious. Now they're unresponsive to touch.

Like we need to capture that in our documentation and our our assessments, right? This can change it. Within our own shifts, we need to also relay that to the next clinicians or in rounds and our be able to come and say, Hey, they were negative one when I started my shift. Now they're negative five.

Something's

going on.

[00:31:04] Annie: And can you do an accurate RAS on someone who is a stroke patient, right? I'm asking this because I, I had a patient who had a stroke and she had uncle herniation and she was very, very drowsy. And like, is this an appropriate time to use RAS?

[00:31:21] Kali: Yeah, I think so. Yeah. And so when we just say patients are sleepy, , we've kind of just kind of accept that. As a medical term term, but we need to be using RAS, because sleepy can be negative one and negative five, but those can be very different presentations.

And, if they change something's cost it to change.

[00:31:43] Annie VO: Kaylee's breakdown of how to properly assess the Raz. Highlights how critical clear communication is in healthcare. Especially for complex topics like neurological status. So when nurses, doctors, and other team members use consistent language and assessment tools, like the RAs, it ensures that everyone is on the same page regarding a patient sedation level. As Kayley emphasized vague terms like sleepy can mean anything from ERASs of minus one to minus five.

Whereas being specific about a patient's response to verbal and tactile stimulation makes their status crystal clear.

To wrap things up a proper RAs assessment starts with an observation.

If your patient is alert and calm, they score zero. If the patient is sedated, approach them and without touching, don't touch. Say their name and ask them to make eye contact with you. If they make eye contact with you for more than 10 seconds, they're minus one. If they make eye contact with you for less than 10 seconds. They're minus two. If they respond, but didn't make direct eye contact. That's a minus three. Now if they don't respond to verbal stimulation. Next you want to apply physical stimulation such as the sternal rub. If they respond to that. There minus four. And if they don't respond to nauseous, stimuli, There are minus five. Now. As you may have noticed, we haven't really talked about the agitated, the plus one to plus for a spectrum of the rest.

And that's because we don't really see it use all that much because we aren't assigning goals to agitation.

Like we are to sedation. But with that little caveat out of the way, if a patient is anxious appearing, but not really doing anything. That's a plus one. If they are anxious with non purposeful movement or having ventilator dyssynchrony that's a plus too. If they're more than that. Pulling out lines and tubes. That's a plus three. And if they are overtly combative to sell for staff, that's a plus for.

All right.

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