Scale

Label

Description

+4

Combative

Combative, violent , immediate danger to staff

+3

Very agitated

Pulls to remove tubes or catheters; aggressive

+2

Agitated

Frequent non-purposeful movement, fights ventilator

+1

Restless

Anxious, apprehensive, movement, not aggressive

0

Alert and calm

Spontaneously pays attention to caregiver

−1

Drowsy

Not fully alert, but has sustained awakening to voice (eye opening and contact >10 sec)

−2

Light sedation

Briefly awakens to voice (eyes open and contact < 10 sec)

−3

Moderate sedation

Movement or eye opening to voice (no eye contact)