Score
Level
Description
−5
Unarousable
No response to voice or physical stimulation
−4
Deep Sedation
No response to voice; any movement to physical stimulation
−3
Moderate Sedation
Movement/eye opening to voice, no eye contact
−2
Light Sedation
Brief eye opening/contact (<10 sec) to voice
−1
Drowsy
Eye opening/contact >10 sec to voice
0
Alert & Calm TARGET
Spontaneously awake and calm
+1
Restless
Anxious but movements not aggressive or vigorous
+2
Agitated
Frequent non-purposeful movement, fights ventilator
+3
Very Agitated
Pulls/removes tubes, aggressive
+4
Combative
Overtly combative, violent, immediate danger to staff