Critical care pain observation tool

Indicator	Description	Score
Facial expression	No muscular tension observed	Relaxed, neutral	0
	Presence of frowning, brow lowering, orbit tightening, and levator contraction	Tense	1
	All of the above facial movements plus eyelid tightly closed	Grimacing	2
Body movements	Does not move at all (does not necessarily mean absence of pain)	Absence of movements	0
	Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements	Protection	1
	Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed	Restlessness	2
Muscle tension	No resistance to passive movements	Relaxed	0
Evaluation by passive flexion and extension of upper extremities	Resistance to passive movements	Tense, rigid	1
	Strong resistance to passive movements, inability to complete them	Very tense or rigid	2
Compliance with the ventilator (intubated patients)	Alarms not activated, easy ventilation	Tolerating ventilator or movement	0
	Alarms stop spontaneously	Coughing but tolerating	1
	Asynchrony: blocking ventilation, alarms frequently activated	Fighting ventilator	2
OR
Vocalization (extubated patients)	Talking in normal tone or no sound	Talking in normal tone or no sound	0
	Sighing, moaning	Sighing, moaning	1
	Crying out, sobbing	Crying out, sobbing	2
Total, range			0-8

Republished with permission of American Association of Critical-Care Nurses, from Stites M, Observational pain scales in critically ill adults, Critical Care Nurse, 2013, Vol 33, Pg 68; permission conveyed through Copyright Clearance Center, Inc.

Graphic 103691 Version 3.0

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Critical care pain observation tool