II. Indications
III. Criteria
- Facial Expression
- Score 0: Relaxed or neutral
- Score 1: Tense
- Score 2: Grimace
- Body Movements
- Score 0: Absent movements
- Score 1: Protective body movements
- Score 2: Restless
-
Muscle Tension
- Score 0: Relaxed
- Score 1: Tense and rigid tone
- Score 2: Very tense and rigid tone
- Vocalization (extubated patients) or Ventilator Compliance (intubated patients)
- Score 0: No sound or speaking in normal tone, or tolerating Ventilator and movement
- Score 1: Sighs and moans, or tolerating Ventilator but coughing, and alarms stop spontaneously
- Score 2: Cries and sobs, or fighting Ventilator
IV. Interpretation: Total Score (0 to 8)
- Score <=2
- Adequate pain control
- Score >2
- Inadequate pain control
- Increase analgesia or sedation