II. Protocol: Scoring

  1. Score 1: Absent
  2. Score 2: Slight
    1. Does not prevent patient from conducting other appropriate behavior
  3. Score 3: Moderate
    1. Requires redirection from agitated to appropriate behavior
  4. Score 4: Extreme
    1. Despite redirection attempts, agitation persists

III. Protocol: Behaviors (assign a score of 1 to 4 to each of the following 14)

  1. Short attention span, easy distractibility, inability to concentrate
  2. Impulsive, impatient, low tolerance for pain or frustration
  3. Uncooperative, resistant to care or demanding
  4. Violent and or threatening Violence toward people or property
  5. Explosive or unpredictable anger
  6. Rocking, rubbing, moaning or other self-stimulating behavior
  7. Pulling at tubes or restraints
  8. Wandering from treatment areas
  9. Restlessness, pacing, or excessive movement
  10. Repetitive behaviors (motor or verbal)
  11. Rapid, loud or excessive talking.
  12. Sudden changes of mood.
  13. Excessive crying or laughing.
  14. Self-abusiveness (physical or verbal)

IV. Protocol: Interpretation (total score)

  1. Score 36 or higher
    1. Severe agitation
  2. Score 29 to 35
    1. Moderate agitation
  3. Score 22 to 28
    1. Mild agitation
  4. Score <22
    1. No significant agitation

V. Resources

  1. COMBI Agitated Behavior Scale (pdf)
    1. http://www.tbims.org/combi/abs/abs.pdf

VI. References

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