Date/time 1 Date/time 2

Sticker with

Behavior Scale Date/time 3 Date/time 4 patient’s name

Place a mark
1 2 3 4

Alertness 1. deeply asleep (eyes closed, no response to changes in the environment)

2. lightly asleep (eyes mostly closed, occasional responses)
3. drowsy (child closes his/her eyes frequently, less responsive to the environment)
4. awake and alert (child responsive to the environment)
5. awake and hyper-alert (exaggerated responses to environmental stimuli)

Calmness/ 1. calm (child appears serene and tranquil)

Agitation 2. slightly anxious (child shows slight anxiety)
3. anxious (child appears agitated but remains in control)
4. very anxious (child appears very agitated, just able to control)
5. panicky (severe distress with loss of control)

Respiratory 1. no spontaneous respiration

response 2. spontaneous and ventilator respiration
(only in mechanically 3. restlessness or resistance to ventilator
ventilated children) 4. actively breathes against ventilator or coughs regularly
5. fights ventilator

Crying 1. quiet breathing, no crying sounds

(only in spontaneously 2. occasional sobbing or moaning
breathing children) 3. whining (monotonous sound)
4. crying
5. screaming or shrieking

Physical 1. no movement
movement 2. occasional, (three or fewer) slight movements
3. frequent, (more than three) slight movements
4. vigorous movements limited to extremities
5. vigorous movements including torso and head

Muscle tone 1. muscles totally relaxed; no muscle tone

2. reduced muscle tone; less resistance than normal
3. normal muscle tone
4. increased muscle tone and flexion of fingers and toes
5. extreme muscle rigidity and flexion of fingers and toes

Facial tension 1. facial muscles totally relaxed

2. normal facial tone
3. tension evident in some facial muscles (not sustained)
4. tension evident throughout facial muscles (sustained)
© Copyright English version: Monique van Dijk en Erwin Ista

5. facial muscles contorted and grimacing

Total score

NRS pain* .... .... .... .... estimate of pain (0 = no pain to 10 = worst possible pain)
NISS* .... .... .... .... fill in: 1. insufficient sedation, 2. adequate sedation or 3. oversedation

Details sedatives/
analgesics
Reason assessment

(Before or after medication or standard assessment) *Abbreviations: NRS = Numeric Rating Score, NISS = Nurse Interpretation of Sedation Sale