Version May 2024
| Score | Term | Description |
| +4 | Combative | Overtly combative or violent, immediate danger to staff |
| +3 | Very agitated | Pulls on or removes tubes or catheters, aggressive behavior toward staff |
| +2 | Agitated | Frequent nonpurposeful movement or patient-ventilator dyssynchrony |
| +1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
| 0 | Alert and calm | |
| -1 | Drowsy | Not fully alert, sustained (>10 seconds) awakening, eye contact to voice |
| -2 | Light sedation | Briefly (<10 seconds) awakens with eye contact to voice |
| -3 | Moderate sedation | Any movement (but no eye contact) to voice |
| -4 | Deep sedation | No response to voice, any movement to physical stimulation |
| -5 | Unarousable | No response to voice or physical stimulation |
| Procedure | ||
| 1. | Observe patient. Is patient alert and calm (score 0)? | |
| 2. | Does patient have behavior that is consistent with restlessness or agitation? | |
| Assign score +1 to +4 using the criteria listed above. | ||
| 3. | If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker. | |
| Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1). | ||
| Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2). | ||
| Patient has any movement in response to voice, excluding eye contact (score -3). | ||
| 4. | If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response. | |
| Patient has any movement to physical stimulation (score -4). | ||
| Patient has no response to voice or physical stimulation (score -5). | ||
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