RIC
HM
ON
D A
GIT
ATI
ON
-SED
ATI
ON
SC
ALE
(RA
SS)
Sc
ale
L
abel
D
escr
iptio
n
STEP
Seda
tion
Ass
essm
ent
-4
D
EEP
SED
ATI
ON
No
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng
to p
hysi
cal s
timul
atio
n
-5
U
NA
RO
USE
AB
LE
N
o re
spon
se to
voi
ce o
r phy
sica
l stim
ulat
ion
If R
ASS
is -4
or -
5
STO
P (p
atie
nt u
ncon
scio
us),
REC
HEC
K la
ter
T O U C H
+4
CO
MB
ATI
VE
Com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
staf
f +3
VE
RY
AG
ITA
TED
Pulls
to re
mov
e tu
bes
or c
athe
ters
; agg
ress
ive
+2
AG
ITA
TED
Fr
eque
nt n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r +1
R
ESTL
ESS
Anx
ious
, app
rehe
nsiv
e, m
ovem
ents
not
agg
ress
ive
0
A
LER
T &
CA
LM
Sp
onta
neou
sly
pays
atte
ntio
n to
car
egiv
er
-1
DR
OW
SY
Not
fully
ale
rt, b
ut h
as s
usta
ined
aw
aken
ing
to v
oice
(e
ye o
peni
ng &
con
tact
>10
sec
)
-2
LIG
HT
SED
ATI
ON
Brie
fly a
wak
ens
to v
oice
(eye
s op
en &
con
tact
<10
sec
)
-3
MO
DER
ATE
SED
ATI
ON
M
ovem
ent o
r eye
ope
ning
to v
oice
(no
eye
cont
act)
If R
ASS
is ≥
-3 p
roce
ed to
CA
M-IC
U (I
s pa
tient
CA
M-IC
U p
ositi
ve o
r neg
ativ
e?)
V O I C E
Ses
sler
, et a
l., A
m J
Rep
ir C
rit C
are
Med
200
2, 1
66: 1
338-
1344
E
ly, e
t al.,
JA
MA
2003
; 286
, 298
3-29
91
RIC
HM
ON
D A
GIT
ATI
ON
-SED
ATI
ON
SC
ALE
(RA
SS)
Sc
ale
L
abel
D
escr
iptio
n
STEP
Seda
tion
Ass
essm
ent
-4
D
EEP
SED
ATI
ON
No
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng
to p
hysi
cal s
timul
atio
n
-5
U
NA
RO
USE
AB
LE
N
o re
spon
se to
voi
ce o
r phy
sica
l stim
ulat
ion
If R
ASS
is -4
or -
5
STO
P (p
atie
nt u
ncon
scio
us),
REC
HEC
K la
ter
T O U C H
+4
CO
MB
ATI
VE
Com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
staf
f +3
VE
RY
AG
ITA
TED
Pulls
to re
mov
e tu
bes
or c
athe
ters
; agg
ress
ive
+2
AG
ITA
TED
Fr
eque
nt n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r +1
R
ESTL
ESS
Anx
ious
, app
rehe
nsiv
e, m
ovem
ents
not
agg
ress
ive
0
A
LER
T &
CA
LM
Sp
onta
neou
sly
pays
atte
ntio
n to
car
egiv
er
-1
DR
OW
SY
Not
fully
ale
rt, b
ut h
as s
usta
ined
aw
aken
ing
to v
oice
(e
ye o
peni
ng &
con
tact
>10
sec
)
-2
LIG
HT
SED
ATI
ON
Brie
fly a
wak
ens
to v
oice
(eye
s op
en &
con
tact
<10
sec
)
-3
MO
DER
ATE
SED
ATI
ON
M
ovem
ent o
r eye
ope
ning
to v
oice
(no
eye
cont
act)
If R
ASS
is ≥
-3 p
roce
ed to
CA
M-IC
U (I
s pa
tient
CA
M-IC
U p
ositi
ve o
r neg
ativ
e?)
V O I C E
Ses
sler
, et a
l., A
m J
Rep
ir C
rit C
are
Med
200
2, 1
66: 1
338-
1344
E
ly, e
t al.,
JA
MA
2003
; 286
, 298
3-29
91
RIC
HM
ON
D A
GIT
ATI
ON
-SED
ATI
ON
SC
ALE
(RA
SS)
Sc
ale
L
abel
D
escr
iptio
n
STEP
Seda
tion
Ass
essm
ent
-4
D
EEP
SED
ATI
ON
No
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng
to p
hysi
cal s
timul
atio
n
-5
U
NA
RO
USE
AB
LE
N
o re
spon
se to
voi
ce o
r phy
sica
l stim
ulat
ion
If R
ASS
is -4
or -
5
STO
P (p
atie
nt u
ncon
scio
us),
REC
HEC
K la
ter
T O U C H
+4
CO
MB
ATI
VE
Com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
staf
f +3
VE
RY
AG
ITA
TED
Pulls
to re
mov
e tu
bes
or c
athe
ters
; agg
ress
ive
+2
AG
ITA
TED
Fr
eque
nt n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r +1
R
ESTL
ESS
Anx
ious
, app
rehe
nsiv
e, m
ovem
ents
not
agg
ress
ive
0
A
LER
T &
CA
LM
Sp
onta
neou
sly
pays
atte
ntio
n to
car
egiv
er
-1
DR
OW
SY
Not
fully
ale
rt, b
ut h
as s
usta
ined
aw
aken
ing
to v
oice
(e
ye o
peni
ng &
con
tact
>10
sec
)
-2
LIG
HT
SED
ATI
ON
Brie
fly a
wak
ens
to v
oice
(eye
s op
en &
con
tact
<10
sec
)
-3
MO
DER
ATE
SED
ATI
ON
M
ovem
ent o
r eye
ope
ning
to v
oice
(no
eye
cont
act)
If R
ASS
is ≥
-3 p
roce
ed to
CA
M-IC
U (I
s pa
tient
CA
M-IC
U p
ositi
ve o
r neg
ativ
e?)
V O I C E
Ses
sler
, et a
l., A
m J
Rep
ir C
rit C
are
Med
200
2, 1
66: 1
338-
1344
E
ly, e
t al.,
JA
MA
2003
; 286
, 298
3-29
91
RIC
HM
ON
D A
GIT
ATI
ON
-SED
ATI
ON
SC
ALE
(RA
SS)
Sc
ale
L
abel
D
escr
iptio
n
STEP
Seda
tion
Ass
essm
ent
-4
D
EEP
SED
ATI
ON
No
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng
to p
hysi
cal s
timul
atio
n
-5
U
NA
RO
USE
AB
LE
N
o re
spon
se to
voi
ce o
r phy
sica
l stim
ulat
ion
If R
ASS
is -4
or -
5
STO
P (p
atie
nt u
ncon
scio
us),
REC
HEC
K la
ter
T O U C H
+4
CO
MB
ATI
VE
Com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
staf
f +3
VE
RY
AG
ITA
TED
Pulls
to re
mov
e tu
bes
or c
athe
ters
; agg
ress
ive
+2
AG
ITA
TED
Fr
eque
nt n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r +1
R
ESTL
ESS
Anx
ious
, app
rehe
nsiv
e, m
ovem
ents
not
agg
ress
ive
0
A
LER
T &
CA
LM
Sp
onta
neou
sly
pays
atte
ntio
n to
car
egiv
er
-1
DR
OW
SY
Not
fully
ale
rt, b
ut h
as s
usta
ined
aw
aken
ing
to v
oice
(e
ye o
peni
ng &
con
tact
>10
sec
)
-2
LIG
HT
SED
ATI
ON
Brie
fly a
wak
ens
to v
oice
(eye
s op
en &
con
tact
<10
sec
)
-3
MO
DER
ATE
SED
ATI
ON
M
ovem
ent o
r eye
ope
ning
to v
oice
(no
eye
cont
act)
If R
ASS
is ≥
-3 p
roce
ed to
CA
M-IC
U (I
s pa
tient
CA
M-IC
U p
ositi
ve o
r neg
ativ
e?)
V O I C E
Ses
sler
, et a
l., A
m J
Rep
ir C
rit C
are
Med
200
2, 1
66: 1
338-
1344
E
ly, e
t al.,
JA
MA
2003
; 286
, 298
3-29
91
Con
fusi
on A
sses
smen
t Met
hod
for t
he IC
U (C
AM
-ICU
) ST
EPD
ELIR
IUM
ASS
ESSM
ENT
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
Upo
sitiv
eD
ELIR
IUM
Pre
sent
4. D
isor
gani
zed
Thin
king
:
1.
Will
a s
tone
floa
t on
wat
er?
2. A
re th
ere
fish
in th
e se
a?
3. D
oes
one
poun
d w
eigh
mor
e th
an tw
o?
4. C
an y
ou u
se a
ham
mer
to p
ound
a n
ail?
Com
man
d: “
Hol
dup
this
man
y fin
gers
” (H
old
up 2
fing
ers)
“N
ow d
o th
e sa
me
thin
g w
ith th
e ot
her h
and”
(Do
not d
emon
stra
te)
OR
“
Add
one
mor
e fin
ger”
(If p
atie
nt u
nabl
e to
mov
e bo
th a
rms)
0 - 1
Erro
r
> 1
Erro
r
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
3. A
ltere
d Le
vel o
f Con
scio
usne
ss
Cur
rent
RA
SS le
vel (
thin
k ba
ck to
sed
atio
n as
sess
men
t in
Step
1)
RA
SS o
ther
th
an z
ero
RA
SS =
zer
o
2. In
atte
ntio
n:
“Squ
eeze
my
hand
whe
n I s
ay th
e le
tter ‘
A’.”
Rea
d th
e fo
llow
ing
sequ
ence
of l
ette
rs: S
A V
E A
H A
A R
T
ERR
OR
S : N
o sq
ueez
e w
ith ‘A
’ & S
quee
ze o
n le
tter o
ther
than
‘A’
If u
nabl
e to
com
plet
e Le
tters
P
ictu
res
0 - 2
Er
rors
> 2
Erro
rs
NO
1. A
cute
Cha
nge
or F
luct
uatin
g C
ours
e of
Men
tal S
tatu
s:
Is th
ere
an a
cute
cha
nge
from
men
tal s
tatu
s ba
selin
e?
OR
Has
the
patie
nt’s
men
tal s
tatu
s flu
ctua
ted
durin
g th
e pa
st 2
4 ho
urs?
YES
Cop
yrig
ht ©
200
2, E
. Wes
ley
Ely
, MD
, MP
H a
nd V
ande
rbilt
Uni
vers
ity, a
ll rig
hts
rese
rved
• • ••
Con
fusi
on A
sses
smen
t Met
hod
for t
he IC
U (C
AM
-ICU
) ST
EPD
ELIR
IUM
ASS
ESSM
ENT
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
Upo
sitiv
eD
ELIR
IUM
Pre
sent
4. D
isor
gani
zed
Thin
king
:
1.
Will
a s
tone
floa
t on
wat
er?
2. A
re th
ere
fish
in th
e se
a?
3. D
oes
one
poun
d w
eigh
mor
e th
an tw
o?
4. C
an y
ou u
se a
ham
mer
to p
ound
a n
ail?
Com
man
d: “
Hol
dup
this
man
y fin
gers
” (H
old
up 2
fing
ers)
“N
ow d
o th
e sa
me
thin
g w
ith th
e ot
her h
and”
(Do
not d
emon
stra
te)
OR
“
Add
one
mor
e fin
ger”
(If p
atie
nt u
nabl
e to
mov
e bo
th a
rms)
0 - 1
Erro
r
> 1
Erro
r
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
3. A
ltere
d Le
vel o
f Con
scio
usne
ss
Cur
rent
RA
SS le
vel (
thin
k ba
ck to
sed
atio
n as
sess
men
t in
Step
1)
RA
SS o
ther
th
an z
ero
RA
SS =
zer
o
2. In
atte
ntio
n:
“Squ
eeze
my
hand
whe
n I s
ay th
e le
tter ‘
A’.”
Rea
d th
e fo
llow
ing
sequ
ence
of l
ette
rs: S
A V
E A
H A
A R
T
ERR
OR
S : N
o sq
ueez
e w
ith ‘A
’ & S
quee
ze o
n le
tter o
ther
than
‘A’
If u
nabl
e to
com
plet
e Le
tters
P
ictu
res
0 - 2
Er
rors
> 2
Erro
rs
NO
1. A
cute
Cha
nge
or F
luct
uatin
g C
ours
e of
Men
tal S
tatu
s:
Is th
ere
an a
cute
cha
nge
from
men
tal s
tatu
s ba
selin
e?
OR
Has
the
patie
nt’s
men
tal s
tatu
s flu
ctua
ted
durin
g th
e pa
st 2
4 ho
urs?
YES
Cop
yrig
ht ©
200
2, E
. Wes
ley
Ely
, MD
, MP
H a
nd V
ande
rbilt
Uni
vers
ity, a
ll rig
hts
rese
rved
• • ••
Con
fusi
on A
sses
smen
t Met
hod
for t
he IC
U (C
AM
-ICU
) ST
EPD
ELIR
IUM
ASS
ESSM
ENT
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
Upo
sitiv
eD
ELIR
IUM
Pre
sent
4. D
isor
gani
zed
Thin
king
:
1.
Will
a s
tone
floa
t on
wat
er?
2. A
re th
ere
fish
in th
e se
a?
3. D
oes
one
poun
d w
eigh
mor
e th
an tw
o?
4. C
an y
ou u
se a
ham
mer
to p
ound
a n
ail?
Com
man
d: “
Hol
dup
this
man
y fin
gers
” (H
old
up 2
fing
ers)
“N
ow d
o th
e sa
me
thin
g w
ith th
e ot
her h
and”
(Do
not d
emon
stra
te)
OR
“
Add
one
mor
e fin
ger”
(If p
atie
nt u
nabl
e to
mov
e bo
th a
rms)
0 - 1
Erro
r
> 1
Erro
r
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
3. A
ltere
d Le
vel o
f Con
scio
usne
ss
Cur
rent
RA
SS le
vel (
thin
k ba
ck to
sed
atio
n as
sess
men
t in
Step
1)
RA
SS o
ther
th
an z
ero
RA
SS =
zer
o
2. In
atte
ntio
n:
“Squ
eeze
my
hand
whe
n I s
ay th
e le
tter ‘
A’.”
Rea
d th
e fo
llow
ing
sequ
ence
of l
ette
rs: S
A V
E A
H A
A R
T
ERR
OR
S : N
o sq
ueez
e w
ith ‘A
’ & S
quee
ze o
n le
tter o
ther
than
‘A’
If u
nabl
e to
com
plet
e Le
tters
P
ictu
res
0 - 2
Er
rors
> 2
Erro
rs
NO
1. A
cute
Cha
nge
or F
luct
uatin
g C
ours
e of
Men
tal S
tatu
s:
Is th
ere
an a
cute
cha
nge
from
men
tal s
tatu
s ba
selin
e?
OR
Has
the
patie
nt’s
men
tal s
tatu
s flu
ctua
ted
durin
g th
e pa
st 2
4 ho
urs?
YES
Cop
yrig
ht ©
200
2, E
. Wes
ley
Ely
, MD
, MP
H a
nd V
ande
rbilt
Uni
vers
ity, a
ll rig
hts
rese
rved
• • ••
Con
fusi
on A
sses
smen
t Met
hod
for t
he IC
U (C
AM
-ICU
) ST
EPD
ELIR
IUM
ASS
ESSM
ENT
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
Upo
sitiv
eD
ELIR
IUM
Pre
sent
4. D
isor
gani
zed
Thin
king
:
1.
Will
a s
tone
floa
t on
wat
er?
2. A
re th
ere
fish
in th
e se
a?
3. D
oes
one
poun
d w
eigh
mor
e th
an tw
o?
4. C
an y
ou u
se a
ham
mer
to p
ound
a n
ail?
Com
man
d: “
Hol
dup
this
man
y fin
gers
” (H
old
up 2
fing
ers)
“N
ow d
o th
e sa
me
thin
g w
ith th
e ot
her h
and”
(Do
not d
emon
stra
te)
OR
“
Add
one
mor
e fin
ger”
(If p
atie
nt u
nabl
e to
mov
e bo
th a
rms)
0 - 1
Erro
r
> 1
Erro
r
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
CA
M-IC
U n
egat
ive
NO
DEL
IRIU
M
3. A
ltere
d Le
vel o
f Con
scio
usne
ss
Cur
rent
RA
SS le
vel (
thin
k ba
ck to
sed
atio
n as
sess
men
t in
Step
1)
RA
SS o
ther
th
an z
ero
RA
SS =
zer
o
2. In
atte
ntio
n:
“Squ
eeze
my
hand
whe
n I s
ay th
e le
tter ‘
A’.”
Rea
d th
e fo
llow
ing
sequ
ence
of l
ette
rs: S
A V
E A
H A
A R
T
ERR
OR
S : N
o sq
ueez
e w
ith ‘A
’ & S
quee
ze o
n le
tter o
ther
than
‘A’
If u
nabl
e to
com
plet
e Le
tters
P
ictu
res
0 - 2
Er
rors
> 2
Erro
rs
NO
1. A
cute
Cha
nge
or F
luct
uatin
g C
ours
e of
Men
tal S
tatu
s:
Is th
ere
an a
cute
cha
nge
from
men
tal s
tatu
s ba
selin
e?
OR
Has
the
patie
nt’s
men
tal s
tatu
s flu
ctua
ted
durin
g th
e pa
st 2
4 ho
urs?
YES
Cop
yrig
ht ©
200
2, E
. Wes
ley
Ely
, MD
, MP
H a
nd V
ande
rbilt
Uni
vers
ity, a
ll rig
hts
rese
rved
• • ••