Score |
Description |
Definition |
-3 |
Unresponsive |
- No spontaneous respiratory effort
- No cough or coughs only with suctioning
- No response to noxious stimuli
- Unable to pay attention to care provider
- Does not distress with any procedure (including noxious)
- Does not move
|
-2 |
Responsive to Noxious Stimuli |
- Spontaneous yet supported breathing
- Coughs with suctioning/repositioning
- Responds to noxious stimuli
- Unable to pay attention to care provider
- Will distress with a noxious procedure
- Does not move/occasional movement of extremities or shifting of position
|
-1 |
Responsive to Gentle Touch or Voice |
- Spontaneous but ineffective non-supported breaths
- Coughs with suctioning/repositioning
- Responds to touch/voice
- Able to pay attention but drifts off after stimulation
- Distresses with procedures
- Able to calm with comforting touch or voice when stimulus removed
- Occasional movement of extremities or shifting of position
|
0 |
Awake and Able to Calm |
- Spontaneous and effective breathing
- Coughs when repositioned/occasional spontaneous cough
- Responds to voice/no external stimulus is required to elicit response
- Spontaneously pays attention to care provider
- Distresses with procedures
- Able to calm with comforting touch or voice when stimulus removed
- Occasional movement of extremities or shifting of position/increased movement (restless, squirming)
|
+1 |
Restless and Difficult to Calm |
- Spontaneous effective breathing/having difficulty breathing with ventilator
- Occasional spontaneous cough
- Responds to voice/no external stimulus is required to elicit response
- Drifts off/spontaneously pays attention to care provider
- Intermittently unsafe
- Does not consistently calm despite 5-minute attempt/unable to console
- Increased movement (restless, squirming)
|
+2 |
Agitated |
- May have difficulty breathing with ventilator
- Coughing spontaneously
- No external stimulus required to elicit response
- Spontaneously pays attention to care provider
- Unsafe (biting ETT, pulling at lines, cannot be left alone)
- Unable to console
- Increased movement (restless, squirming or thrashing side-to-side, kicking legs)
|