Table 1: Modified comfort scale.
Alertness | Deeply asleep | 1 | ||||
Lightly asleep | 2 | |||||
Drowsy | 3 | |||||
Fully awake and alert | 4 | |||||
Hyper alert | 5 | |||||
Muscle tone | No muscle tone | 1 | ||||
Reduced | 2 | |||||
Normal | 3 | |||||
Increased | 4 | |||||
Extreme muscle rigidity | 5 | |||||
Calmness | Calm, quite breathing (no crying) | 1 | ||||
Slightly anxious, easily distracted by touch or voice (sobbing) | 2 | |||||
Anxious, difficult to distract (moaning) | 3 | |||||
Very anxious, impossible to distract (crying) | 4 | |||||
Panicky (screaming) | 5 | |||||
Physical movement | No movement | 1 | ||||
Occasional slight movements | 2 | |||||
Frequent slight movements | 3 | |||||
Vigorous movements of the extremities | 4 | |||||
Vigorous movements, including head and torso | 5 | |||||
Facial tension | Facial muscles totally relaxed (smile) | 1 | ||||
No facial muscle tension evident (serious) | 2 | |||||
Tension evident in some facial muscles (frown) | 3 | |||||
Tension evident throughout facial muscles (clenched teeth) | 4 | |||||
Facial muscles contorted and grimacing | 5 | |||||
Respiratory rate (bpm) | Age\Points | 1 | 2 | 3 | 4 | 5 |
< 1 year | < 30 | 30-40 | 41-50 | 51-60 | > 60 | |
1-5 years | < 25 | 25-35 | 36-50 | 51-60 | > 60 | |
5-12 years | < 20 | 20-25 | 25-35 | 36-50 | > 50 | |
>12 years | < 15 | 15-20 | 21-35 | 36-50 | > 50 | |
Heart rate (bpm) | Age\Points | 1 | 2 | 3 | 4 | 5 |
< 1 year | < 110 | 110-160 | 161-180 | 181-200 | > 200 | |
1-5 years | < 95 | 95-140 | 141-160 | 161-180 | > 180 | |
5-12 years | < 80 | 80-120 | 121-140 | 141-160 | > 160 | |
> 12 years | < 60 | 60-100 | 101-120 | 121-140 | > 140 |