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
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
validity and reliability, and the authors cannot accept responsibility for errors or omission or for any
consequences resulting from the application or interpretation of this material.
Assessment of Sedation
 Sedation is scored in addition to pain for each behavioral and
physiological criteria to assess the infant’s response to stimuli
 Sedation does not need to be assessed/scored with every pain
assessment/score
 Sedation is scored from 0  -2 for each behavioral and
physiological criteria, then summed and noted as a negative score (0
 -10)
 A score of 0 is given if the infant’s response to stimuli is
normal for their gestational age
 Desired levels of sedation vary according to the situation
 “Deep sedation”  score of -10 to -5 as goal
 “Light sedation”  score of -5 to –2 as goal
 Deep sedation is not recommended unless an infant
is receiving ventilatory support, related to the high potential for
apnea and hypoventilation
 A negative score without the administration of opioids/
sedatives may indicate:
 The premature infant’s response to prolonged or
persistent pain/stress
 Neurologic depression, sepsis, or other pathology
Premature + 3 if < 28 weeks gestation / corrected age
Pain + 2 if 28-31 weeks gestation / corrected age
Assessment
+ 1 if 32-35 weeks gestation / corrected age
Assessment of Pain/Agitation
 Pain assessment is the fifth vital sign – assessment for
pain should be included in every vital sign assessment
 Pain is scored from 0  +2 for each behavioral and
physiological criteria, then summed
 Points are added to the premature infant’s pain score
based on their gestational age to compensate for their limited
ability to behaviorally or physiologically communicate pain
 Total pain score is documented as a positive number (0 
+10)
 Treatment/interventions are indicated for scores > 3
 Interventions for known pain/painful stimuli are indicated
before the score reaches 3
 The goal of pain treatment/intervention is a score  3
 More frequent pain assessment indications:
 Indwelling tubes or lines which may cause pain, especially
with movement (e.g. chest tubes)  at least every 2-4 hours
 Receiving analgesics and/or sedatives  at least every 2-4
hours
 30-60 minutes after an analgesic is given for pain
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 Whaley’s

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