RASS镇静评分.docx

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1、Table1.TheRichmondAgitation-SedationScale(RASS)ScoreTermDescription+4CanbativeOvertlycombative,violent.immediatedangertostaff+3VeryagitatedPdlsOfremovestube(Ofcatheters);aggressre+2AgitatedFrequentnopurposefimovement,fightsventilator1RestlessAnxiousbutmovementsnotaggressiveOCvigorousOAlertandcalm- 1

2、DrowsyNo(fulyaletl.buthassustainedawakening(eyeOPening/eyecontact)toVOiCe(lSeCOndS)- 21.ightsedationBrieflyawakensvheyecontacttovoice(10SeCOndS)- 3ModerateMOVementoreyeOPeningtOgCe(butnoeyecontact)sedation.Verbalstimulation-4DeepsedationNoresponsetovoice,butmovementoreyeoperg-toPhySiCalStimUIation-5

3、UnarsabteNoresponsetovoioephysicalstimulation_PhysicalStknuIatiOTProcedureforRASSAssessment1. ObservepatientPatientisalert,restless,agitated.ScoreOto+42. IfnOtatert.statepatentsnameandsaytoopeneyesandlookatspeaker. Fientawakensvhsustanedeyeopeningandeyecon-Score-1tact. PatientakesVtheyeopenngandeyec

4、ontact,butnotScore-2sustained. PatienthasanymovementinresponsetovoicebuteyeScore-3ootact.3. WhennoresponsetoverbalStmiation.pysicaiystimulatepatienttyskingshoulderand/orrubbingsternum. PatienthasanymovementtophysicalStirulation.Score-4 Patienthasresponsetoarystimulation.Score-5AdaptedwhpormiS9,29RASS冷静程度评估表(RichmondAgitation-SedationScale)+4方攻击性有暴力行为+3特别躁动试着拔出呼吸管,目管或隐脉点滴+2躁动焦虑身体激烈移动，无法协作呼吸机+1担心焦虑焦虑惊慌但身体只有稍微的移动O醒悟安静醒悟自然状态-1昏昏欲睡没有完全醒悟，但可保持醒悟超过十秒-2轻度冷静无法维持醒悟超过十秒-3中度冷静对声音行反应-4型度冷静对身体剌激有反应-5昏迷对声音与身体刺激都无反应