The nurse wants to assess consciousness, agitation, anxiety, sleep, and ventilatory synchrony in a client with a traumatic brain injury. Which scale should the nurse use for this assessment?
1. Ramsay Sedation
2. Riker Sedation-Agitation
3. AACN Sedation Assessment
4. Richmond Agitation-Sedation
3
Rationale 1: The Ramsay Sedation Scale assesses arousability and is useful whenever sedative drugs or narcotics are administered, but cannot be used for the client receiving neuromuscular blocking drugs.
Rationale 2: The Riker Sedation-Agitation scale defines degrees of agitation.
Rationale 3: The AACN Sedation Assessment Scale is most comprehensive, evaluating five domains: consciousness, agitation, anxiety, sleep, and client-ventilator synchrony.
Rationale 4: The Richmond Agitation–Sedation Scale distinguishes between responses to verbal and physical stimuli. This 10-level scale has confirmed validity and reliability for use in sedated and non-sedated clients.
Global Rationale: The AACN Sedation Assessment Scale is most comprehensive, evaluating five domains: consciousness, agitation, anxiety, sleep, and client-ventilator synchrony. The Ramsay Sedation Scale assesses arousability and is useful whenever sedative drugs or narcotics are administered, but cannot be used for the client receiving neuromuscular blocking drugs. The Riker Sedation-Agitation scale defines degrees of agitation. The Richmond Agitation–Sedation Scale distinguishes between responses to verbal and physical stimuli. This 10-level scale has confirmed validity and reliability for use in sedated and non-sedated clients.
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