Table 2 Critical Care Pain Observational Tool
From: Evaluating and monitoring analgesia and sedation in the intensive care unit
Indicator | Description | Score |
|---|---|---|
Facial expression | No muscular tension observed | Relaxed, neutral: 0 |
| Â | Presence of frowning, brow lowering, orbit tightening, and levator contraction | Tense: 1 |
| Â | 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 |
| Â | Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements | Protection: 1 |
| Â | 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 |
| Â | Resistance to passive movements | Tense, rigid: 1 |
| Â | Strong resistance to passive movements, inability to complete them | Very tense or rigid: 2 |
Compliance with the ventilator | Alarms not activated, easy ventilation | Tolerating ventilator or movement: 0 |
| Â | Alarms stop spontaneously | Coughing but tolerating: 1 |
| Â | 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 |
| Â | Sighing, moaning | Sighing, moaning: 1 |
| Â | Crying out, sobbing | Crying out, sobbing: 2 |