Negative sounding noise on inspiration or expiration: breathing looks strenuous, labored, or wearing: respirations sound loud, harsh, or gasping: difficulty breathing or trying hard at attempting to achieve a good gas exchange; episodic bursts of rapid breaths or hyperventilation.
Noise or speech with a negative or disapproving quality: hushed low sounds such as constant muttering with a guttural tone: monotone, subdued, or varying pitched noise with a definite unpleasant sound: faster rate than a conversation or drawn out as in a moan or groan: repeating the same words with a mournful tone: expressing hurt or pain.
Content Facial Expression
Pleasant, calm looking face, tranquil, at ease, or serene: relaxed facial expression with a slack unclenched jaw: overall look is one of peace.
Sad Facial Expression
Troubled-looking face, looking hurt, worried, lost, or lonesome: distressed appearance: sunken “hang dog” look with lackluster eyes: tears: crying.
Frightened Facial Expression
Scared, concerned-looking face: looking bothered, fearful, or troubled: alarmed appearance with open eyes and pleading face.
Face looks strained: or scowling looks: displeased expression with a wrinkled brow and creases in the forehead: corners of mouth turned down.
Relaxed Body Language
Easy openhanded position: look of being in a restful position: may be cuddled up or stretched out: muscles look of normal firmness and joints are without stress: look of being idle/lazy or “laid back”: appearance of “ just killing the day” casual.
Tense Body Language
Extremities show tension: wringing of hands: clenched fists, or knees pulled up tightly: look of being in a strained and inflexible position.
Restless inpatient motion, acting squirmy or jittery appearance of trying to get away from hurt area, forceful touching, tugging or rubbing of body parts.
Rating Scale: 0=None, 1=Low, 2=Moderate, 3=High
Adapted from Hurley AC, Volicer BJ, Hanrahan PA, et al. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992; 15:369-377