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Critical Care Pain Observational Tool |
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| Indicator |
Description |
Score |
|
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| 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 |
| 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 |
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 |
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Scores for each of the four domains are summed, with a total score of 0 to 8 [34]. | ||
Sessler et al. Critical Care 2008 12(Suppl 3):S2 doi:10.1186/cc6148 |
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