Table 1.
Score | Term | Description |
+4 | Combative | Overtly combative or violent and an 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 | |
-1 | Drowsy | Not fully alert but has sustained (> 10 seconds) awakenings, with eye contact, to voice |
-2 | Light sedation | Briefly (< 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 stimuli |
-5 | Unarousable | No response to voice or physical stimulation |