+4 Combative, violent, danger to staff. +3 Very agitated, pulls tubes/catheters. +2 Agitated, frequent non-purposeful movement. +1 Restless, anxious but movements not aggressive. 0 Alert and calm. -1 Drowsy, awakens to voice (eyes open >10 sec). -2 Light sedation, awakens to voice (eyes open <10 sec). -3 Moderate sedation, movement/eye opening to voice. -4 Deep sedation, response only to physical stimulation. -5 Unarousable, no response to voice/pain.