From: Evaluating and monitoring analgesia and sedation in the intensive care unit
Item | Description | Score |
---|---|---|
Facial expression | Relaxed | 1 |
 | Partially tightened (for example, brow lowering) | 2 |
 | Fully tightened (for example, eyelid closing) | 3 |
 | Grimacing | 4 |
Upper limbs | No movement | 1 |
 | Partially bent | 2 |
 | Fully bent with finger flexion | 3 |
 | Permanently retracted | 4 |
Compliance with ventilation | Tolerating movement | 1 |
 | Coughing but tolerating ventilation for most of the time | 2 |
 | Fighting ventilator | 3 |
 | Unable to control ventilation | 4 |