Score | Description | Example |
---|---|---|
7 | Dangerous agitation | Pulling at endotracheal tube, trying to remove catheters, climbing over bedrails, thrashing from side to side, striking at staff |
6 | Very agitated | Patient does not calm down in response to verbal instructions or reassurance, requires physical restraint, biting endotracheal tube |
5 | Agitated | Anxious or agitated but calms down in response to verbal instructions or reassurance |
4 | Calm, cooperative | Calm, easily rousable, follows commands |
3 | Sedated | Difficult to rouse, awakens to verbal stimuli or gentle shaking but drifts off again, will follow simple commands |
2 | Very sedated | Can be roused by physical stimuli but does not communicate or follow commands, may move spontaneously |
1 | Not rousable | May move or grimace minimally to stimuli but does not communicate or follow commands |