Assessment

Sedation

Normal

Pain / Agitation

Criteria

-2

-1

0

1

2

Crying Irritability

No cry with painful stimuli

Moans or cries briefly with painful stimuli

Little crying

Not irritable

Irritable or crying at intervals

Consolable

High-pitched or              silent-continuous cry      

Inconsolable

Behavior

State

Does not arouse to any stimuli

No spontaneous movement

Arouses minimally to stimuli

Little spontaneous movement

Appropriate for gestational age

Restless sleep

Awakens frequently

Constantly awake or

Arouses minimally                       (not sedated)

Facial

Expression

Mouth is lax

No expression

Minimal expression with stimuli

Relaxed

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

­ hi 10-20% from baseline

SaO₂ ¯ to 76-85% with stimulation – quick ­

­hi > 20% from baseline

SaO₂ ¯ to £ 75% with stimulation – slow ­

Out of sync with vent