nicu-picu/Forms/Sedation-Scoring/FRM-SED-001-COMFORT-Scale.md

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.