What does a RASS score of +3 indicate?

• A. Combative, violent, immediate danger to self or others
• B. Very agitated, aggressive, concern for future violence
• C. Restless, anxious, apprehensive but not yet agitated
• D. Alert and calm

Answer: (B)

RASS measures agitation and sedation on a scale from +4 to -5, with positive numbers signaling increasing agitation. A score of +3 means the patient is very agitated and may be aggressive, with concern for potential violence toward others. You might see nonpurposeful or forceful movements, pulling at tubes, shouting, or attempting to break away. This level is more intense than simple restlessness or anxiety (which would be around +1) but not as extreme as +4, which is combative and violent. A calm, alert state is 0, and negative numbers indicate varying depths of sedation.