Crying / Irritability -2 ® No response to painful stimuli, e.g.: ¬
No cry with needle sticks ¬
No reaction to ETT or nares
suctioning ¬
No response to care giving -1 ® Moans, sighs, or cries (audible or silent)
minimally to painful stimuli, e.g.
needle sticks, ETT or nares suctioning, care giving 0 ® Not irritable – appropriate
crying ¬
Cries briefly with normal stimuli ¬
Easily consoled ¬
+1 ® Infant is irritable/crying at intervals – but can be consoled ¬ If intubated – intermittent silent cry +2 ® Any of the following: ¬
Cry is high-pitched ¬
Infant cries inconsolably ¬
If intubated –
silent continuous cry |
     |
|
Behavior / State -2 ® Does not arouse or react to any stimuli: ¬
Eyes continually shut or open ¬
No spontaneous movement -1 ® Little spontaneous movement, arouses briefly
and/or minimally to any stimuli: ¬
Opens eyes briefly ¬
Reacts to suctioning ¬
Withdraws to pain 0
® Behavior and
state are gestational age appropriate -2 ® Any of the following: ¬ Restless, squirming ¬ Awakens frequently/easily with minimal or no stimuli +2 ® Any of the following: ¬
Kicking ¬
Arching ¬
Constantly awake ¬
No movement or minimal arousal with
stimulation (inappropriate for gestational age or clinical situation, i.e.
post-operative) |
||
Facial Expression -2 ® Any of the following: ¬
Mouth is lax ¬
Drooling ¬
No facial expression at rest or with
stimuli -1 ® Minimal facial expression with stimuli 0 ® Face is relaxed at
rest but not lax – normal expression with stimuli +1 ® Any pain face expression observed intermittently +2 ® Any pain face expression is continual |
 |
|
Extremities / Tone-2 ® Any of the following: ¬
No palmar or planter grasp can be elicited ¬
Flaccid tone -1 ® Any of the following: ¬
Weak palmar or planter grasp can be
elicited ¬
Decreased tone 0
® Relaxed hands and feet –
normal palmar or sole grasp
elicited – appropriate tone for gestational age +1 ® Intermittent (<30 seconds duration)
observation of toes and/or hands as clenched or fingers splayed ¬
Body is not tense +2 ® Any of the following: ¬
Frequent (≥30 seconds duration)
observation of toes and/or hands as clenched, or fingers splayed ¬
Body is tense/stiff |
||
|
Vital
Signs: HR, BP, RR, & O2 Saturations -2 ® Any of the following: ¬
No variability in vital signs with stimuli ¬
Hypoventilation ¬
Apnea ¬
Ventilated infant – no spontaneous
respiratory effort -1 ® Vital signs show little variability with stimuli
– less than 10%
from baseline 0 ® Vital signs and/or oxygen saturations are within normal
limits with normal variability – or normal for gestational age +1 ® Any of the following: ¬
HR, RR, and/or BP are 10-20% above baseline ¬
With care/stimuli infant desaturates
minimally to moderately (SaO2 76-85%) and recovers quickly (within 2 minutes) +2 ® Any of the following: ¬
HR, RR, and/or BP are > 20% above
baseline ¬
With care/stimuli infant desaturates
severely (SaO2
< 75%) and recovers slowly (> 2 minutes) ¬ Infant is out of syynchrony with the ventilator - fighting the ventalator |
||