Observation Item |
1
Normal |
3
Moderate Impairment |
5
Severe Impairment |
Quality of Cry |
Strong with normal tone OR Content and not crying |
Whimpering OR Sobbing |
Weak OR Moaning OR High Pitched |
| Reaction to parent stimulation |
Cries briefly then stops OR Content and not crying |
Cries off and on |
Continual cry OR Hardly responds |
| State variation |
If awake, stays awake OR If asleep and stimulated, wakes up quickly |
Eyes close briefly, awake OR Awakes with prolonged stimuation |
Falls to sleep OR Will not respond |
| Colour |
Pink |
Pale extremities OR Acrocyanosis |
Pale OR Cyanotic OR Mottled OR Ashen |
| Hydration |
Skin normal, eyes normal AND Mucous membranes moist |
Skin, eyes normal AND Mouth slightly dry |
Skin doughy OR Tented AND Dry mucous membranes AND/OR Sunken eyes |
| Response (talk, smile) to social overtures |
Smile OR Alerts
(<=2 mo) |
Brief smile OR Alerts briefly (<=2 mo) |
NO smile, dull, expressionless OR No Alerting (<=2 mo) |
