7 | Dangerous agitation | Pulling at tracheal tube, trying to remove catheters, climbing over the bed rail, striking at staff, thrashing from side to side |
6 | Very agitated | Does not calm down despite frequent verbal reminders of limits, require physical restraints, biting endotracheal tube |
5 | Agitated | Anxious or mildly agitated, attempting to sit up, calms down with verbal instructions |
4 | Non-agitated | Calm and cooperative |
3 | Sedated | Calm, awakens easily, follows commands, difficult to arouse, awakens to verbal stimuli or gentle shaking, but drifts off again, follows simple commands |
2 | Very sedated | Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously |
1 | Unarousable | Minimal or no response to noxious stimuli, does not communicate or follow commands |