129 lines
3.3 KiB
Markdown
129 lines
3.3 KiB
Markdown
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# COMFORT Sedation Assessment Scale
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| Form ID | FRM-SED-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Assessment Date | |
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| Assessment Time | |
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| Assessed By | |
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## COMFORT Scale Scoring
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### 1. Alertness
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- [ ] 1 - Deeply asleep (eyes closed, no response to changes)
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- [ ] 2 - Lightly asleep (eyes mostly closed, occasional response)
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- [ ] 3 - Drowsy (eyes mostly closed, occasional response to environment)
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- [ ] 4 - Fully awake and alert
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- [ ] 5 - Hyperalert (exaggerated responses to stimuli)
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### 2. Calmness/Agitation
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- [ ] 1 - Calm (no agitation, peaceful)
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- [ ] 2 - Slightly anxious (slightly anxious but easily reassured)
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- [ ] 3 - Anxious (anxious, not easily reassured)
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- [ ] 4 - Very anxious (very anxious, resistant to treatment)
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- [ ] 5 - Panicky (panicky, fighting/pulling at tubes)
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### 3. Respiratory Response (for ventilated patients)
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- [ ] 1 - No spontaneous respirations
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- [ ] 2 - Spontaneous respirations with little response to ventilator
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- [ ] 3 - Occasional cough or resistance to ventilator
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- [ ] 4 - Actively breathes against ventilator
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- [ ] 5 - Fights ventilator, coughing regularly
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### 4. Physical Movement
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- [ ] 1 - No movement
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- [ ] 2 - Occasional slight movement
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- [ ] 3 - Frequent slight movement
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- [ ] 4 - Vigorous movement limited to extremities
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- [ ] 5 - Vigorous movement including torso and head
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### 5. Blood Pressure (MAP) Baseline
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**Baseline MAP:** ______ mmHg
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- [ ] 1 - MAP below baseline
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- [ ] 2 - MAP consistently at baseline
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- [ ] 3 - Infrequent elevations ≥15% above baseline
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- [ ] 4 - Frequent elevations ≥15% above baseline
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- [ ] 5 - Sustained elevation ≥15% above baseline
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### 6. Heart Rate Baseline
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**Baseline HR:** ______ bpm
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- [ ] 1 - HR below baseline
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- [ ] 2 - HR consistently at baseline
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- [ ] 3 - Infrequent elevations ≥15% above baseline
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- [ ] 4 - Frequent elevations ≥15% above baseline
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- [ ] 5 - Sustained elevation ≥15% above baseline
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### 7. Muscle Tone
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- [ ] 1 - Muscles totally relaxed, no muscle tone
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- [ ] 2 - Reduced muscle tone
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- [ ] 3 - Normal muscle tone
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- [ ] 4 - Increased muscle tone and flexion of fingers and toes
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- [ ] 5 - Extreme muscle rigidity and flexion of fingers and toes
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### 8. Facial Tension
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- [ ] 1 - Facial muscles totally relaxed
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- [ ] 2 - Facial muscle tone normal, no facial tension
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- [ ] 3 - Tension evident in some facial muscles
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- [ ] 4 - Tension evident throughout facial muscles
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- [ ] 5 - Facial muscles contorted and grimacing
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## Total Score
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**Total COMFORT Score:** ______ / 40
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## Score Interpretation
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- **8-16**: Over-sedated
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- **17-26**: Optimal sedation range
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- **27-40**: Under-sedated
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## Clinical Action
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### Current Sedation
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| Medication | Dose | Rate |
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|------------|------|------|
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### Action Taken Based on Score
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- [ ] No change needed
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- [ ] Increase sedation
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- [ ] Decrease sedation
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- [ ] Notify physician
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- [ ] Other: ____________
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### Comments
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## Signature
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| Role | Name | Signature | Date/Time |
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|------|------|-----------|-----------|
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| RN/RT | | | |
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---
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*Form FRM-SED-001 Rev 1.0*
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**Reference:** Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992.
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