- Score 1: Absent
- Score 2: Slight
- Does not prevent patient from conducting other appropriate behavior
- Score 3: Moderate
- Requires redirection from agitated to appropriate behavior
- Score 4: Extreme
- Despite redirection attempts, Agitation persists
- Protocol
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Behaviors (assign a score of 1 to 4 to each of the following 14)
- Short attention span, easy distractibility, inability to concentrate
- Impulsive, impatient, low tolerance for pain or frustration
- Uncooperative, resistant to care or demanding
- Violent and or threatening Violence toward people or property
- Explosive or unpredictable anger
- Rocking, rubbing, moaning or other self-stimulating behavior
- Pulling at tubes or restraints
- Wandering from treatment areas
- Restlessness, pacing, or excessive movement
- Repetitive behaviors (motor or verbal)
- Rapid, loud or excessive talking.
- Sudden changes of mood.
- Excessive crying or laughing.
- Self-abusiveness (physical or verbal)
- Protocol
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Interpretation (total score)
- Score 36 or higher
- Severe Agitation
- Score 29 to 35
- Moderate Agitation
- Score 22 to 28
- Mild Agitation
- Score <22
- No significant Agitation
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