MODIFIED RICHMOND AGITATION AND SEDATION SCALE (mRASS)

Observe patient
1. Patient is alert, restless, or agitated. (score 0 to +4)
If not alert, state patient's name and say to open eyes and look at speaker. Ask 'Describe how you are feeling?'
1. Patient awakens with sustained eye opening and eye contact. (score -1)
2. Patient awakens with eye opening and eye contact, but not sustained. (score -2)
3. Patient has any movement in response to voice but no eye contact. (score -3)
When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum
1. Patient has any movement to physical stimulation. (score -4)
2. Patient has no response to any stimulation. (score -5)

Score	Term	Description
+4	Combative	No attention; overtly combative, violent, immediate danger to staff
+3	Very agitated	Very distractible; repeated calling or touch required to get or keep eye contact or attention.; cannot focus; pulls or removes tube(s) or catheter(s); aggressive; fights environment not people
+2	Slightly agitated	Easily distractible; rapidly loses attention; resists care or uncooperative; frequent non-purposeful movement
+1	Restless	Slightly distractible; pays attention most of the time; anxious, but cooperative; movements not aggressive or vigorous
0	Alert and calm	Pays attention; makes eye contact; aware of surroundings; responds immediately and appropriately to calling name and touch
-1	Wakes easily	Slightly drowsy; eye contact
-2	Wakes slowly	Very drowsy; pays attention some of the time; briefly awakens with eye contact to voice >10 seconds
-3	Difficult to wake	Repeated calling or touch required to get or keep eye contact or attention; needs repeated stimuli (touch or voice) for attention, movement, or eye opening to voice (but no eye contact)
-4	Can't stay awake	Arousable but no attention; no response to voice, but movement or eye opening to physical stimulation
-5	Unarousable	No response to voice or physical stimulation

mRASS Diagram

Heartbrain