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State Behavioral Scale (SBS)

State Behavioral Scale (SBS) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


State Behavioral Scale (SBS)
1

Score as patient’s response to voice then touch then noxious stimuli
(Planned ETT suctioning or <5 seconds of nail bed pressure)
Score Description Definition
-3


Unresponsive
No spontaneous respiratory effort
No cough or coughs only with suctioning
No response to noxious stimuli
Unable to pay attention to care provider
Does not distress with any procedure (including noxious)
Does not move

-2


Responsive to
noxious stimuli
Spontaneous yet supported breathing
Coughs with suctioning/repositioning
Responds to noxious stimuli
Unable to pay attention to care provider
Will distress with a noxious procedure
Does not move/occasional movement of extremities or shifting of position

-1


Responsive to
gentle touch
or voice
Spontaneous but ineffective non-supported breaths
Coughs with suctioning/repositioning
Responds to touch/voice
Able to pay attention but drifts off after stimulation
Distresses with procedures
Able to calm with comforting touch or voice when stimulus removed
Occasional movement of extremities or shifting of position
0



Awake and
Able to calm
Spontaneous and effective breathing
Coughs when repositioned/Occasional spontaneous cough
Responds to voice/No external stimulus is required to elicit response
Spontaneously pays attention to care provider
Distresses with procedures
Able to calm with comforting touch or voice when stimulus removed
Occasional movement of extremities or shifting of position/increased movement
(restless, squirming)
+1



Restless and
difficult to calm
Spontaneous effective breathing/Having difficulty breathing with ventilator
Occasional spontaneous cough
Responds to voice/ No external stimulus is required to elicit response
Drifts off/ Spontaneously pays attention to care provider
Intermittently unsafe
Does not consistently calm despite 5 minute attempt/unable to console
Increased movement (restless, squirming)
+2


Agitated
May have difficulty breathing with ventilator
Coughing spontaneously
No external stimulus required to elicit response
Spontaneously pays attention to care provider
Unsafe (biting ETT, pulling at lines, cannot be left alone)
Unable to console
Increased movement (restless, squirming or thrashing side-to-side, kicking legs)