|
Assessment
|
Sedation
|
Sedation/Pain
|
Pain
/ Agitation
|
|
Criteria
|
-2
|
-1
|
0/0
|
1
|
2
|
|
Crying Irritability
|
No cry with painful stimuli
|
Moans or cries minimally with painful stimuli
|
No sedation/
No pain signs
|
Irritable or crying at intervals
Consolable
|
High-pitched or silent-continuous cry
Inconsolable
|
|
Behavior State
|
No arousal to any stimuli
No spontaneous movement
|
Arouses minimally to stimuli
Little spontaneous movement
|
No sedation/
No pain signs
|
Restless, squirming
Awakens frequently
|
Arching, kicking
Constantly awake or
Arouses minimally / no movement (not sedated)
|
|
Facial Expression
|
Mouth
is lax
No expression
|
Minimal
expression with stimuli
|
No sedation/
No pain signs
|
Any pain expression intermittent
|
Any pain expression continual
|
|
Extremities Tone
|
No grasp reflex
Flaccid tone
|
Weak grasp reflex
¯ muscle tone
|
No sedation/
No pain signs
|
Intermittent clenched toes, fists or finger splay
Body is not tense
|
Continual clenched toes, fists, or finger splay
Body is tense
|
|
Vital
Signs HR, RR, BP,
SaO2
|
No variability with stimuli
Hypoventilation or apnea
|
< 10% variability from baseline with stimuli
|
No sedation/
No pain signs
|
↑ 10-20% from
baseline
SaO2 76-85% with stimulation –
quick recovery
|
↑ 20% from
baseline
SaO2 £
75% with stimulation –
slow recovery
Out of sync with vent
|
