Pat Hummel MA, RNC, NNP, PNP, APN/CNP & Mary Puchalski MS, RNC, APN/CNS

Assessment Sedation Normal Pain / Agitation

Criteria -2 -1 0 1 2
Moans or cries Appropriate Irritable or crying at High-pitched or
Crying No cry with
minimally with crying intervals silent-continuous cry
Irritability painful stimuli
painful stimuli Not irritable Consolable Inconsolable
No arousal to any Arouses minimally Arching, kicking
Behavior stimuli to stimuli Appropriate for Restless, squirming Constantly awake or
State No spontaneous Little spontaneous gestational age Awakens frequently Arouses minimally / no
movement movement movement (not sedated)
Facial Mouth is lax Minimal expression Relaxed Any pain expression Any pain expression
Expression No expression with stimuli Appropriate intermittent continual
Relaxed hands Intermittent clenched Continual clenched toes,
Extremities No grasp reflex Weak grasp reflex
and feet toes, fists or finger splay fists, or finger splay
Tone Flaccid tone muscle tone
Normal tone Body is not tense Body is tense
No variability > 20% from baseline
Vital Signs < 10% variability Within baseline 10-20% from baseline
with stimuli SaO2 75% with
HR, RR, BP, from baseline or normal for SaO2 76-85% with
Hypoventilation with stimuli gestational age stimulation slow
SaO2 stimulation quick
or apnea Out of sync with vent
 Hummel & Puchalski (Rev. 8/14/01)
Loyola University Health System, Loyola University Chicago, 2000 Premature + 3 if < 28 weeks gestation / corrected age
Pain + 2 if 28-31 weeks gestation / corrected age
All rights reserved. No part of this document may 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 Assessment
validity and reliability, and the authors cannot accept responsibility for errors or omission or for any + 1 if 32-35 weeks gestation / corrected age
consequences resulting from the application or interpretation of this material.

Assessment of Sedation Assessment of Pain/Agitation

Sedation is scored in addition to pain for each behavioral and Pain assessment is the fifth vital sign assessment for
physiological criteria to assess the infants response to stimuli pain should be included in every vital sign assessment
Sedation does not need to be assessed/scored with every pain Pain is scored from 0 +2 for each behavioral and
assessment/score physiological criteria, then summed
Sedation is scored from 0 -2 for each behavioral and Points are added to the premature infants pain score
physiological criteria, then summed and noted as a negative score (0 based on their gestational age to compensate for their limited
-10) ability to behaviorally or physiologically communicate pain
A score of 0 is given if the infants response to stimuli is Total pain score is documented as a positive number (0
normal for their gestational age +10)
Desired levels of sedation vary according to the situation Treatment/interventions are indicated for scores > 3
Deep sedation score of -10 to -5 as goal Interventions for known pain/painful stimuli are indicated
Light sedation score of -5 to 2 as goal before the score reaches 3
Deep sedation is not recommended unless an infant The goal of pain treatment/intervention is a score 3
is receiving ventilatory support, related to the high potential for More frequent pain assessment indications:
apnea and hypoventilation Indwelling tubes or lines which may cause pain, especially
A negative score without the administration of opioids/ with movement (e.g. chest tubes) at least every 2-4 hours
sedatives may indicate: Receiving analgesics and/or sedatives at least every 2-4
The premature infants response to prolonged or hours
persistent pain/stress 30-60 minutes after an analgesic is given for pain
Neurologic depression, sepsis, or other pathology behaviors to assess response to medication
Post-operative at least every 2 hours for 24-48
hours, then every 4 hours until off medications
Pavulon/Paralysis
It is impossible to behaviorally evaluate a paralyzed infant for pain
Increases in heart rate and blood pressure may be the only indicator of a need for more analgesia
Analgesics should be administered continuously by drip or around-the-clock dosing
Higher, more frequent doses may be required if the infant is post-op, has a chest tube, or other pathology (such as NEC) that would
normally cause pain
Opioid doses should be increased by 10% every 3-5 days as tolerance will occur without symptoms of inadequate pain relief

Scoring Criteria
 -1 Any of the 0 Vital signs and/or
Crying / Irritability Reacts to
following: oxygen
suctioning
-2 No response to painful Weak palmar or saturations are
Withdra
stimuli, e.g.: planter grasp within normal
ws to pain
No cry can be elicited limits with normal
with needle sticks 0 Behavior and state are Decreased tone variability or
No gestational age normal for
0 Relaxed hands
reaction to ETT or appropriate gestational age
and feet normal
nares suctioning
+1 Any of the following: palmar or sole +1 Any of the
No
Restless, grasp elicited following:
response to care
squirming appropriate tone HR,
giving
Awakens for gestational RR, and/or BP
-1 Moans, sighs, or cries frequently/easily age are 10-20%
(audible or silent) with minimal or no above baseline
+1 Intermittent (<30
minimally to painful stimuli With
seconds duration)
stimuli, e.g. needle care/stimuli
+2 Any of the following: observation of
sticks, ETT or nares infant
Kicking toes and/or hands
suctioning, care giving desaturates
Arching as clenched or
minimally
0 Not irritable Constantly fingers splayed
to moderately
appropriate crying awake Body is not
(SaO2 76-85%)
Cries No movement tense
and recovers
briefly with normal or minimal arousal quickly (within
+2 Any of the
stimuli with stimulation 2 minutes)
following:
Easily (inappropriate for
Frequent (30
consoled gestational age or +2 Any of the
seconds
Normal clinical situation, i.e. following:
duration)
for gestational age post-operative) HR,
observation of
RR, and/or BP
+1 Infant is toes and/or
are > 20%
irritable/crying at Facial Expression hands asBrows:
lowered, drawn together above baseline
intervals but can be clenched, or
-2 Any of the following: With
consoled fingers splayed Forehead:
Mouth is bulge between brows, care/stimuli
If Body is vertical furrows infant
intubated lax tense/stiff
Drooling desaturates
intermittent silent Eyes:
tightly closed severely
cry No facial
expression at rest (SaO2 < 75%)
Vital Signs: HR, Cheeks:
and recovers
+2 Any of the following: or
raised
BP, slowly (> 2
Cry is with stimuli
Nose:
RR, broadened, bulging
minutes)
high-pitched
-1 Minimal facial & O2 Infan
Infant Nasolabial fold:
expression with Satur deepened
t is out of
cries inconsolably Mouth:
stimuli ationopen, squarish
synchrony
If
s of physical distress and pain in with
Facial expression the infant
the
intubated silent 0 Face is relaxed at Reproduced with permission from Wong DL, Hess CS: Wong and Whaleys

continuous cry -2 Any of the ventilator

Clincial Manual of Pediatric Nursing, Ed. 5, 2000, Mosby, St. Louis

rest but not lax

following: fighting the
normal expression
No We ventilator
value your opinion.
with stimuli
Behavior / State variability in Pat Hummel,
+1 Any pain face vital signs with MA, RNC, NNP, PNP, APN/CNP
-2 Does not arouse or Phone/voice mail: 708-327-9055
expression observed stimuli
react to any stimuli: Email: phummel@lumc.edu
intermittently Hypove
Eyes
ntilation Mary Puchalski,
continually shut or +2 Any pain face MS, RNC, APN/CNS
open expression is Apnea
Phone: 630-833-1400
No continual Ventilate
X41114
spontaneous d infant no
movement Extremities / Tone spontaneous Email: marypuch@comcast.net
respiratory
-1 Little spontaneous -2 Any of the
effort
movement, arouses following:
briefly and/or No palmar or -1 Vital signs show
minimally to any planter grasp little variability
stimuli: can be elicited with stimuli less
Opens Flaccid tone than 10% from
eyes briefly baseline