Nonverbal Pain ScaleLoading...FaceNo particular expression or smile0Occasional grimace, tearing, frowning, wrinkled forehead+1Frequent grimace, tearing, frowning, wrinkled forehead+2Activity (movement)Lying quietly in, normal position0Seeking attention through movement or slow, cautious movement+1Restless, excessive activity and/or withdrawal reflexes+2GuardingLying quietly, no positioning of hands over areas of the body0Splinting areas of the body, tense+1Rigid, stiff+2Physiology (vital signs)Baseline vital signs unchanged0Change in SBP >20 mmHg or HR >20 bpm+1Change in SBP >30 mmHg or HR >25 bpm+2RespiratoryBaseline RR/SpO2 synchronous with ventilator0RR >10 bpm over baseline, 5% decrease SpO2 or mild ventilator asynchrony+1RR >20 bpm over baseline, 10% decrease SpO₂ or severe ventilator asynchrony+2IndikationenHinweise & Vorsichtsmaßnahmen