Table 2

Critical Care Pain Observational Tool

Indicator
Description
Score

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

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