7 |
Severely agitated |
Remove endotracheal tubes, attempt to remove catheters, climb over bedrail, attack staff, thrash sideways |
6 |
Very agitated |
Do not calm down despite frequent verbal reminders of limits, require physical restraints, bite endotracheal tubes |
5 |
Agitated |
Display anxiety or mild agitated, attempt to sit up, calm down on verbal instructions |
4 |
Calm, cooperative |
Calm, easily arousable, follow verbal instructions |
3 |
Sedated |
Difficult to arouse, awaken to verbal stimuli or gentle shaking but drifts off again, follow simple verbal instructions |
2 |
Highly sedated |
Arouse to physical stimuli but do not communicate or follow verbal instructions, may move spontaneously |
1 |
Unarousable |
Minimal or no response to noxious stimuli, do not communicate or follow verbal instructions |