Assign one RASS score using the standard sequence.

Observe spontaneous behaviour and score 0 to +4 when the patient is alert, restless or agitated.
If the patient is not alert, call their name and ask them to open their eyes and look at the speaker. Score -1 to -3 from the response to voice.
If there is no response to voice, apply physical stimulation. Score -4 for movement and -5 for no response.

Score	Level	Implemented criterion
+4	Combative	Violent and an immediate danger to staff or self
+3	Very agitated	Pulls or removes tubes or catheters, or is aggressive
+2	Agitated	Frequent non-purposeful movement or fighting the ventilator
+1	Restless	Anxious or apprehensive, with movements that are not aggressive
0	Alert and calm	Alert and calm
-1	Drowsy	Eye contact to voice for more than 10 seconds
-2	Light sedation	Eye contact to voice for less than 10 seconds
-3	Moderate sedation	Movement or eye opening to voice without eye contact
-4	Deep sedation	Movement or eye opening only to physical stimulation
-5	Unarousable	No response to voice or physical stimulation

Richmond Agitation-Sedation Scale (RASS)