Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade
Kanji et al. found that the CPOT is a valid pain assessment in noncomatose, delirious adult ICU patients
Item
Description
Score
Facial expression
Relaxed
Partly tightened (e.g., brow lowering)
Fully tightened (e.g., eyelid closing)
Grimacing
Upper limbs
No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
Compliance with
ventilation
Tolerating movement
Coughing but tolerating ventilation
most of the time
Fighting ventilator
Unable to control ventilation
Total, range
3β12
aA BPS score > 5 indicates significant pain.
Adapted with permission from: Lippincott Williams & Wilkins/Wolters Kluwer Health. Payen J, Bru O, Bosson J, et al. Assessing pain in critically ill sedated patients
Indicator
Description
Score
Facial expression
No muscular tension observed
Relaxed, neutral
Presence of frowning, brow lowering, β¨orbit
tightening, and levator contraction
Tense
All of the above facial movements plus eyelids
tightly closed
Grimacing
Body movements
Does not move at all (does not necessarily mean
absence of pain)
Absence of movement
Slow, cautious movements; touching or rubbing the
pain site; seeking attention through movements
Protection
Pulling tube, trying to sit up, moving limbs/
thrashing, not following commands, striking at
staff, trying to climb out of bed
Restlessness
Muscle tension
Evaluation by passive
flexion and extension of
upper extremities
No resistance to passive movements
Relaxed
Resistance to passive movements
Tense, rigid
Strong resistance to passive movements, inability
to complete them
Very tense or rigid