Facial activity |
Relaxed facial activity |
0 |
Transient grimaces with frowning, lip purse, and chin quiver or tautness |
1 |
Frequent grimaces, lasting grimaces |
2 |
Permanent grimaces resembling crying or blank face |
3 |
Body movements |
Relaxed body movements |
0 |
Transient agitation, often quiet |
1 |
Frequent agitation but can be calmed down |
2 |
Permanent agitation with contraction of fingers and toes and hypertonia of limbs or infrequent, slow movements, and prostration |
3 |
Quality of sleep |
Falls asleep easily |
0 |
Falls asleep with difficulty |
1 |
Frequent, spontaneous arousals, independent of nursing, restless sleep |
2 |
Spontaneous arousals, independent of nursing, restless sleep |
3 |
Sleepless |
4 |
Quality of contact with nurses |
Smiles, attentive to voice |
0 |
Transient apprehension during interactions with nurses |
1 |
Difficulty communicating with nurses. Cries in response to minor stimulation |
2 |
Refuses to communicate with nurses. No interpersonal rapport. Moans without stimulation |
3 |
Consolability |
Quiet, total relaxation |
0 |
Calms down quickly in response to stroking or voice, or with sucking |
1 |
Calms down with difficulty |
2 |
Disconsolate. Sucks desperately |
3 |