Pat Hummel MA, RNC, NNP, PNP, APN/CNP

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

Loyola University Health System, Loyola University Chicago 2009
(rev. 2/10/09) Pat Hummel, MA, APN, NNP, PNP

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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
+1 if <30 weeks gestation / corrected age.

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