Pain Assessment

Pain Assessment in Critical Care

A vital part of client care is assessing pain assessment in those who are critically ill and/or in intensive care. If they are alert and oriented, they may be able to self-report. They can do so verbally or by pointing to a number if they cannot speak, but clients are often too critically ill to communicate. Additionally, they may be unable to self-report due to factors such as altered levels of consciousness, distress, sedation, and mechanical ventilatory support (Gélinas, 2016; Suzuki, 2017).

In this context, the nurse’s observations of pain indicators are vital to pain assessment. These observations are most often focusing on the behavioural dimensions of pain. Typically, physiological pain indicators do not provide a valid assessment of pain because vital signs are influenced by the client’s condition (i.e., pathological processes) and medications (i.e., and ) that are often used in critical care situations.

Of the many tools used in clinical practice, the Behavioral Pain Scale and the Critical Care Pain Observation Tool are recommended for assessing pain intensity, and often used in critical care (Suzuki, 2017). They are also the most validated and translated tools (Kerbage et al., 2021).

Behavioral Pain Scale (BPS)

The development and psychometric testing of the BPS was published in 2001 by Payen and colleagues (2001), and used for assessment of pain in critically ill clients who are on mechanical ventilation. It is user-friendly and has strong psychometric properties in terms of assessing pain in non-communicative critical care clients (Payen & Gelinas, 2014).

The BPS incorporates three items:

  • Facial expression.
  • Upper limb movement.
  • Compliance with ventilation.

(Payen et al., 2001).

Each item is scored from one to four with higher scores indicating more pain. The cut-off score for when pain is identified as present is greater than five (Payen et al., 2007).


See external link to view the tool:

Critical-Care Pain Observation Tool (CPOT)

The CPOT was developed for assessing pain in ventilated and non-ventilated clients (Gélinas et al., 2006). It was initially developed in French and later translated into English (Gélinas et al., 2009) and other languages.

The CPOT has four components:

  • Facial expression.
  • Body movement.
  • Muscle tension.
  • Compliance with the ventilator for intubated clients or vocalization for extubated clients.

Each of these sections is scored from 0 to 2, yielding a total score from 0 to 8 (Gélinas et al., 2006). The cut-off score indicating pain is a score of greater than two (Gélinas et al., 2009).

Tips for using the CPOT:

  • While at rest, observe the client’s facial expression, body movements, and presence of vocalization for one minute.
  • Next, perform a passive range of motion of the lower arm (flexion and extension of elbow) while holding the client’s hand and elbow to assess for muscle tension.
  • Upon movement (such as turning them on their side), observe the client’s facial expression, body movements, and presence of vocalization.

(Kaiser Permanente National Patient Care Services, 2011).

Check out this external link for the CPOT:

For more information, check out this video on the Critical-Care Pain Observation Tool: How to use it in your ICU Additional guidelines and instructions on using the tool can be located at:


Clinical Tip

Use critical thinking when assessing pain in a critical care client, because self-reporting is often compromised. In critical care, you will encounter situations where pain indicators other than behavioural responses should be considered. Behavioural pain assessment tools should only be used when the client’s motor function is intact: consider other practices for clients with limited or altered motor function such as in cases of deep sedation, paralysis, and brain injury (Gélinas, 2016). Another limitation of behavioural pain assessment tools is they only evaluate the presence of pain and no other characteristics such as intensity (Kerbage et al., 2021).


Gélinas, C., Fillion, L., Puntillo, K., Viens, C., & Fortier, M. (2006). Validation of the Critical-Care Pain Observation Tool in adult patients. American Journal of Critical Care, 15, 420-427.

Gélinas, C., Harel, F., Fillion, L., Puntillo, K., & Johnston, C. (2009). Sensitivity and specificity of the Critical-Care Pain Observation Tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management, 37(1), 58-67.

Gélinas, C. (2016). Pain assessment in the critically ill adult: Recent evidence and new trends. Intensive and Critical Care Nursing, 34, 1-11.

Kerbage, S., Garvey, L., Lambert, G., & Willetts, G. (2021). Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. International Journal of Nursing Studies, 122. 1-22.

Payen, J., Bru, O., Bosson, J., Lagrasta, A., Novel, E., Deschaux, I., Lavagne, P., & Jacquot, C. (2001). Assessing pain in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine, 29(12), 2258-2263.

Payen, J., Chanques, G., Mantz, J., Hercule, C., Auriant, I., Leguillou, J., Binhas, M., Genty, C., Rolland, C., & Bosson, J. (2007). Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology, 106(4), 687-695.

Payen, J., & Gelinas, C. (2014). Measuring pain in non-verbal critically ill patients: Which pain instrument? Critical Care, 18,(5).

Suzuki, T. (2017). Does the combination use of two pain assessment tools have a synergistic effect? Journal of Intensive Care, 5(1), 1-3.


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