RASS (Richmond Agitation Sedation Scale)
+4: Combative: overly combative, violent, immediate danger to staff
+3: Very agitated: removes/ pulls catheter or tube(s); aggressive
+2: Agitated: frequent non-purposeful move
...
RASS (Richmond Agitation Sedation Scale)
+4: Combative: overly combative, violent, immediate danger to staff
+3: Very agitated: removes/ pulls catheter or tube(s); aggressive
+2: Agitated: frequent non-purposeful movement, fights ventilator
+1: Restless: Anxious but movements not aggressive vigorous
0: Alert and calm
Verbal
Stimulation
ver v
(eye-opening/eye contact) to voice (>10 seconds)
-2: Light sedation: Briefly awaken with eye contact to voice (<10 seconds)
-3: Moderated sedation: Movement or eye opening to voice (but no eye
contact)
Physical
Stimulation
-5: Unarousable: No response to voice or physical stimulation
Procedure for RASS Assessment
1. Observe patient.
a. Patient is alert, restless, or agitated. (score 0 to +4)
1. If not alert, state patient’s name and say to open eyes and look at speaker.
a. Patient awakens with sustained eye opening and eye contact. (score -1)
b. Patient awaken with eye opening and eye contact, but not sustained. (score -
2)
c. Patient has any movement in response to voice but no eye contact. (score -
3)
1. When no response to verbal stimulation, physically stimulate patient by
shaking shoulder and/or rubbing sternum.
a. Patient has any movement to physical stimulation (score -4)
b. Patient has no response to any stimulation. (score -5)
Differences between TOXICITY and WITHDRAWALS
CENTRAL NERVOUS SYSTEM DEPRESSANTS:
Produce physiological and psychological dependence and may have crosstolerance, cross-dependency, and an additive effect when take concurrently.
1. ALCOHOL
Lab: blood alcohol concentration (BAC): 0.08% (80 g/dL) legally
intoxicated
Acute toxicity level greater than about 0.35% (350 g/dL)
Intended Effects: relaxation, decreased social anxiety, stress reduction
TOXICITY NP DR MADS WITHDRAWALSVI
FART
a. Nystagmus a. Vomiting
b. Peripheral collapse b. Insomnia
c. Decrease motor skills/LOC c. Fine tremors
d. Respiratory arrest d. Anxiety
e. Memory impairment e. Restlessness
f. Altered judgement f. Tonic clonic seizure/Transient
g. Death f. Restlessness hallucination or illusion
h. Slurred speech g. constrict pupil
i. Dilation pupil
CHRONIC SALTED
a. Sexual dysfunction
b. Acute pancreatitis
c. Liver damage (ranging from fatty liver to cirrhosis)
d. Thiamine deficiency cause Wernicke-Korsakoff syndrome
(confusion, recent memory loss, and confabulation of lost
memories)
e. Erosive gastritis/gastrointestinal bleeding
f. Direct cardiovascular damage
Effect usually start: within 4-12 hr of the last intake of alcohol,
Peak after: 24-48 hr
Alcohol withdrawal delirium: 2-3 days after stop of alcohol and may
last 2-3 days. (48-72hr)
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