|
| Alertness | 1 | Deeply asleep (eyes closed, no response to changes in the environment) |
| 2 | Lightly asleep (eyes mostly closed, occasional responses) |
| 3 | Drowsy (child closes his/her eyes frequently, less responsive to the environment) |
| 4 | Awake and alert (child responsive to the environment) |
| 5 | Awake and hyperalert (exaggerated responses to environmental stimuli) |
| Calmness/agitation | 1 | Calm (child appears serene and tranquil) |
| 2 | Slightly anxious (child shows slight anxiety) |
| 3 | Anxious (child appears agitated but remains in control) |
| 4 | Very anxious (child appears very agitated, just able to control) |
| 5 | Panicky (severe distress with loss of control) |
| Respiratory response (only in mechanically ventilated children) | 1 | No spontaneous respiration |
| 2 | Spontaneous and ventilator respiration |
| 3 | Restlessness or resistance to ventilator |
| 4 | Actively breathes against ventilator or coughs regularly |
| 5 | Fights ventilator |
| Crying (only in spontaneously breathing children) | 1 | Quiet breathing, no crying sounds |
| 2 | Occasional sobbing or moaning |
| 3 | Whining (monotonous sound) |
| 4 | Crying |
| 5 | Screaming or shrieking |
| Physical movement | 1 | No movement |
| 2 | Occasional, (three or fewer) slight movements |
| 3 | Frequent, (more than three) slight movements |
| 4 | Vigorous movements limited to extremities |
| 5 | Vigorous movements including torso and head |
| Muscle tone | 1 | Muscles totally relaxed; no muscle tone |
| 2 | Reduced muscle tone; less resistance than normal |
| 3 | Normal muscle tone |
| 4 | Increased muscle tone and flexion of fingers and toes |
| 5 | Extreme muscle rigidity and flexion of fingers and toes |
| Facial tension | 1 | Facial muscles totally relaxed |
| 2 | Normal facial tone |
| 3 | Tension evident in some facial muscles (not sustained |
| 4 | Tension evident throughout facial muscles (sustained) |
| 5 | Facial muscles contorted and grimacing |
| COMFORT-B score interpretation | Sedation levels: <10 oversedation, >23 undersedation [17] |
Pain >17 along with the numeric rating scale (NRS) > 4 indicate pain [18]
NRS can be substituted for any validated pain tool |
|
