|
Assessment |
Sedation |
|
Pain
/ Agitation |
||
|
Criteria |
-2 |
-1 |
0 |
1 |
2 |
|
Crying Irritability |
No cry with painful stimuli |
Moans or cries minimally with painful stimuli |
Appropriate crying Not irritable |
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 |
Appropriate for gestational age |
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 |
Relaxed Appropriate |
Any pain expression intermittent |
Any pain expression continual |
|
Extremities Tone |
No grasp reflex Flaccid tone |
Weak grasp reflex ¯ muscle tone |
Relaxed hands and feet Normal tone |
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 |
Within baseline or normal for gestational age |
10-20% from
baseline SaO2 76-85% with stimulation – |
> 20% from
baseline SaO2 £
75% with stimulation – Out of sync with vent |
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be reproduced in any form or by any means,
electronic or mechanical without written permission of the authors.
This tool is currently undergoing testing for validity and reliability,
and the authors cannot accept responsibility for errors or omision or for any
consequences resulting from the application or interpretation of this material
+2 if 28 - 31 weeks gestation / corrected age.
+1 if 32 - 35 weeks gestation / corrected age.
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|