II. Criteria

  1. Breathing independent of vocalization
    1. Score 0: Normal
    2. Score 1: Occasional labored breathing with short periods of Hyperventilation
    3. Score 2: Noisy, labored breathing with longer periods of Hyperventilation (e.g. Cheyne-Stokes)
  2. Negative vocalization
    1. Score 0: None
    2. Score 1: Low level speech with negative or disapproving quality with occasional moan or groan
    3. Score 2: Repeated troubled calling out with loud moaning, groaning, and crying
  3. Facial expression
    1. Score 0: Smiling or inexpressive
    2. Score 1: Sad, frightened or frowning
    3. Score 2: Facial grimacing
  4. Body language
    1. Score 0: Relaxed
    2. Score 1: Tense, fidgeting, or distressed pacing
    3. Score 2: Rigid with fists clenched or knees pulled up. Pushing, pulling away or striking out
  5. Consolability
    1. Score 0: No need for consolability
    2. Score 1: Distracted or reassured by voice or touch
    3. Score 2: Unable to console, distract or reassure

III. Interpretation

  1. Sum the score from the 5 criteria
  2. Interpret as a Pain Scale
    1. Total score 0: No pain
    2. Total score 10: Severe pain

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