# COMFORT Sedation Assessment Scale

| Form ID | FRM-SED-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

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## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Assessment Date | |
| Assessment Time | |
| Assessed By | |

## COMFORT Scale Scoring

### 1. Alertness

- [ ] 1 - Deeply asleep (eyes closed, no response to changes)
- [ ] 2 - Lightly asleep (eyes mostly closed, occasional response)
- [ ] 3 - Drowsy (eyes mostly closed, occasional response to environment)
- [ ] 4 - Fully awake and alert
- [ ] 5 - Hyperalert (exaggerated responses to stimuli)

### 2. Calmness/Agitation

- [ ] 1 - Calm (no agitation, peaceful)
- [ ] 2 - Slightly anxious (slightly anxious but easily reassured)
- [ ] 3 - Anxious (anxious, not easily reassured)
- [ ] 4 - Very anxious (very anxious, resistant to treatment)
- [ ] 5 - Panicky (panicky, fighting/pulling at tubes)

### 3. Respiratory Response (for ventilated patients)

- [ ] 1 - No spontaneous respirations
- [ ] 2 - Spontaneous respirations with little response to ventilator
- [ ] 3 - Occasional cough or resistance to ventilator
- [ ] 4 - Actively breathes against ventilator
- [ ] 5 - Fights ventilator, coughing regularly

### 4. Physical Movement

- [ ] 1 - No movement
- [ ] 2 - Occasional slight movement
- [ ] 3 - Frequent slight movement
- [ ] 4 - Vigorous movement limited to extremities
- [ ] 5 - Vigorous movement including torso and head

### 5. Blood Pressure (MAP) Baseline

**Baseline MAP:** ______ mmHg

- [ ] 1 - MAP below baseline
- [ ] 2 - MAP consistently at baseline
- [ ] 3 - Infrequent elevations ≥15% above baseline
- [ ] 4 - Frequent elevations ≥15% above baseline
- [ ] 5 - Sustained elevation ≥15% above baseline

### 6. Heart Rate Baseline

**Baseline HR:** ______ bpm

- [ ] 1 - HR below baseline
- [ ] 2 - HR consistently at baseline
- [ ] 3 - Infrequent elevations ≥15% above baseline
- [ ] 4 - Frequent elevations ≥15% above baseline
- [ ] 5 - Sustained elevation ≥15% above baseline

### 7. Muscle Tone

- [ ] 1 - Muscles totally relaxed, no muscle tone
- [ ] 2 - Reduced muscle tone
- [ ] 3 - Normal muscle tone
- [ ] 4 - Increased muscle tone and flexion of fingers and toes
- [ ] 5 - Extreme muscle rigidity and flexion of fingers and toes

### 8. Facial Tension

- [ ] 1 - Facial muscles totally relaxed
- [ ] 2 - Facial muscle tone normal, no facial tension
- [ ] 3 - Tension evident in some facial muscles
- [ ] 4 - Tension evident throughout facial muscles
- [ ] 5 - Facial muscles contorted and grimacing

## Total Score

**Total COMFORT Score:** ______ / 40

## Score Interpretation

- **8-16**: Over-sedated
- **17-26**: Optimal sedation range
- **27-40**: Under-sedated

## Clinical Action

### Current Sedation
| Medication | Dose | Rate |
|------------|------|------|
| | | |
| | | |

### Action Taken Based on Score
- [ ] No change needed
- [ ] Increase sedation
- [ ] Decrease sedation
- [ ] Notify physician
- [ ] Other: ____________

### Comments



## Signature

| Role | Name | Signature | Date/Time |
|------|------|-----------|-----------|
| RN/RT | | | |

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*Form FRM-SED-001 Rev 1.0*

**Reference:** Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992.