SEWS & RASS Scale - drug effects PDF

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Summary

drug effects...

Description

SEWS Symptom Scale Severity of Ethanol Withdrawal Scale ANXIETY: Do you feel that something bad is about to happen to you right now? NAUSEA and DRY HEAVES or VOMITING? SWEATING (includes moist palms, sweating now)? TREMOR: with arms extended, eyes closed AGITATION: fidgety, restless, pacing ORIENTATION: Name, place, date All three Only two Only one or none HALLUCINATIONS Visual, tactile, olfactory, gustatory (any) VITAL SIGNS: ANY of the following Pulse > 110 Diastolic BP >90 Temp >99.6 F or 37.6 C

YES 3 3 2 2 3 0 1 3 3 3

TOTAL SCORE = 1-6 (MILD) 7-12 (MODERATE) 13 or Greater (SEVERE) *Hold Drug if Sedated (i.e. Hold drug if RASS equal to -2 or lower) RASS = Richmond Agitation Sedation Scale Score +4 +3 +2 +1 0 -1

Term Combative Very agitated Agitated Restless Alert & Calm Drowsy

-2 -3 -4

Light sedation Moderate Sedation Deep Sedation

-5

Unarousable

Description Overtly combative, violent, immediate danger to staff Pulls or removes tubes (s) or catheters(s); aggressive Frequent non-purposeful movement Anxious, apprehensive, but movements not aggressive Alert and Calm Not fully alert, but has sustained awakening (eyeopening/eye contact) to voice (>10 sec) Briefy awakens with eye contact to voice (...