*If no bowel movement, chart in the progress notes how long without one, assessment and what interventions were done. 
Student First Name            Last Name

Glasgow Coma Scale/Neurological System:
 
If a patient has an infusion for sedation or received intermittent sedation any route select the score for the RASS (Richmond Agitation-Sedation Scale)

Score

Term

Description

+4
Combative
Overtly combative or violent;
immediate danger to staff

+3
Very agitated
Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff

+2
Agitated
Frequent nonpurposeful movement or patient–ventilator dyssynchrony

+1
Restless
Anxious or apprehensive but movements not aggressive or vigorous

0
Alert and calm
Spontaneously pays attention to caregiver

-1
Drowsy
Not fully alert, but has sustained
(more than 10 seconds) awakening,
with eye contact, to voice

-2
Light sedation
Briefly (less than 10 seconds)
awakens with eye contact to voice

-3
Moderate sedation
Any movement
(but no eye contact) to voice

-4
Deep sedation
No response to voice, but any movement to physical stimulation

-5
Unarousable
No response to voice
or physical stimulation