0
Alert and calm
+1
Restless:
Anxious but movements not aggressive vigorous
+2
Agitated:
Frequent non-purposeful movement, fights ventilator
+3
Very agitated:
Pulls or removes tube(s) or catheter(s); aggresive
+4
Combative:
Overtly combative, violent, immediate danger to staff
-1
Drowsy:
Not fully alert, but ha sustained awakening
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