| 0 | 1 | 2 |
---|---|---|---|
Breath (Independent of vocalization) | Normal | Breathing at times altered Short periods of hyperventilation | Impaired breathing Hyperventilation Cheyne- Stokes |
Vocalization | None | Occasional moans Occasional negative expressions Grinding of teeth | Complaints Cry Scream |
Facial expression | Smiling or Expressionless | Sad Anxious Contract | Grimaces Wide eyes Wrinkled forehead |
Body language | Relaxed | Tense. Nervous movements. Restlessness | Rigidity. Agitation Knees bent. A finalistic jerky movement. Tremor. Rocking. Biting hands |
Consolability | Does not require consolation | Distracted or reassured by voice or touch | Inconsolable, is neither distracted nor reassured |
TOTAL | Â | Â | Â |