| +4 |
Combative |
Overtly combative, violent, immediate danger to staff |
| +3 |
Very agitated |
Pulls or removes tube(s) or catheter(s); aggressive |
| +2 |
Agitated |
Frequent non-purposeful movement, fights ventilator |
| +1 |
Restless |
Anxious but movements not aggressive or vigorous |
| 0 |
Alert and calm |
|
| -1 |
Drowsy |
Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (≥10 seconds) |
| -2 |
Light sedation |
Briefly awakens with eye contact to voice (<10 seconds) |
| -3 |
Moderate sedation |
Movement or eye opening to voice (but no eye contact) |
| -4 |
Deep sedation |
No response to voice, but movement or eye opening to physical stimulation |
| -5 |
Unarousable |
No response to voice or physical stimulation |