III. Criteria

  1. Facial Expression
    1. Score 0: Relaxed or neutral
    2. Score 1: Tense
    3. Score 2: Grimace
  2. Body Movements
    1. Score 0: Absent movements
    2. Score 1: Protective body movements
    3. Score 2: Restless
  3. Muscle Tension
    1. Score 0: Relaxed
    2. Score 1: Tense and rigid tone
    3. Score 2: Very tense and rigid tone
  4. Vocalization (extubated patients) or Ventilator Compliance (intubated patients)
    1. Score 0: No sound or speaking in normal tone, or tolerating Ventilator and movement
    2. Score 1: Sighs and moans, or tolerating Ventilator but coughing, and alarms stop spontaneously
    3. Score 2: Cries and sobs, or fighting Ventilator

IV. Interpretation: Total Score (0 to 8)

  1. Score <=2
    1. Adequate pain control
  2. Score >2
    1. Inadequate pain control
    2. Increase analgesia or sedation
      1. See Sedation and Analgesia in Ventilated Patients

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