*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
The Restraint Charting page and the Risk Assessment pages open in a different browser, so you will not lose your Assessment data. Just remember to go back to the browser that has your Assessment data.
