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

3–12

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, 
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