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Critical care pain observation tool

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