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Assessing Pain in the Critically Ill Adult

Scope and Impact of the Problem


Many critically ill adult patients experience significant pain during hospitalization. In the
intensive care unit (ICU), for example, more than 30% have significant pain at rest, and more
than 50% have significant pain during routine care, such as turning, endotracheal suctioning, and
wound care.1-2
Untreated pain can result in negative consequences, including multisystemic complications and
the development of chronic disabling pain. These results, in turn, may seriously impact the
patients functioning, quality of life, and well-being.3-5 Furthermore, the absence of pain
assessment or an incomplete assessment has been associated with death in the ICU.6
Since pain is multidimensional and subjective,7 the patients self-report is the gold standard for
assessment. However, many adult patients in the ICU cannot self-report pain as a result of an
altered level of consciousness, the administration of sedative agents, and/or mechanical
ventilation.8 The lack of self-reporting makes assessing pain in critically ill patients a challenge
for nurses, who should consider use of alternatives such as observational pain assessment
tools.9-10

Expected Practice and Nursing Actions*


1. Attempt to obtain the patients self-report of pain using validated pain assessment tools
or simple questions. (Level B)
Ensure your unit has implemented a pain assessment policy for all critically ill adults,
using validated tools that are appropriate to each patients capacity to communicate.
Teach patients to use self-report pain scales and communicate in verbal and nonverbal
ways, such as numerical rating scales, pointing, and head nodding.
Perform and document pain assessments routinely, including a baseline evaluation at
the beginning of shifts, evaluations during activities or procedures known to be
painful, and before and after administration of analgesics. Communicate assessments
during patient handoffs.
2. Perform a pain assessment for critically ill adults who are unable to self-report, using a
validated behavioral pain scale, such as the Behavioral Pain Scale (BPS) or the CriticalCare Pain Observation Tool (CPOT). (Level B)
Ensure that your unit provides education and clinical support on the use of behavioral
pain scales and interpretation of the scores.
Develop a pain management protocol that includes appropriate use of pharmacologic
and nonpharmacologic strategies according to pain assessment findings.
3. Avoid referring primarily to vital signs for pain assessment of critically ill adult patients.
(Level C)
Perform pain assessment with validated tools when significant fluctuations in vital
signs are noted.
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4. Consider, as a proxy, asking someone who knows the patient well to identify behavior
that may indicate pain. (Level C)
Encourage comprehensive pain assessments that combine different strategies, such as
behavioral pain scales and proxy reporting by family members or caregivers.

Supporting Evidence
Attempt to obtain the patients self-report using valid tools.
The patients self-report remains the gold standard for pain assessment based on the universal
definition of pain.7 Obtaining a patients self-report should be based on current practice
guidelines from the American Society for Pain Management Nursing10 and the Society of
Critical Care Medicine.9
Validated pain assessment tools should be used as standard practice when caring for critically ill
adult patients. Among pain intensity scales, patients prefer the 0-10 Numeric Rating Scale in
vertical and enlarged format (NRS-V); it is usually the best discriminative tool for use in the
adult ICU.11 Similarly, the 0-10 Faces Pain Thermometer shows reliable and valid results in adult
patients in a postoperative ICU.12
When a patient cannot concentrate on a pain intensity scale, ask a simple question about the
presence of pain. A yes or no answer, indicated by head nodding, head shaking, or other
signs, should be considered a valid self-report of pain.10 In more unstable, critically ill adults, a
self-report on the presence of pain is easier to obtain than a self-report on the intensity of pain.13
Use valid behavioral scales for patients unable to self-report.
Behavioral pain scales should be used routinely to assess pain in critically ill adults who are
unable to self-report. The BPS (scale of 3-12)14 and the CPOT (scale of 0-8)15 are considered the
most valid and reliable tools for use with adults in medical, surgical, and trauma ICUs.16 Both
scales were tested on more than 500 adult patients in the ICU, with good inter-rater reliability
and discriminant validation (ie, both scales discriminated between painful and nonpainful
procedures.13-15,17-24) BPS and CPOT scores also have been positively correlated with patients
self-reports of pain, supporting criterion validation of their use.13,15,18,21
Cutoff scores for the presence of pain were established for the BPS (>5) and the CPOT (>2). A
CPOT cutoff score >2 yielded sensitivity of 86% and specificity of 78%.25
Behavioral pain scales are useful in detecting the presence of pain, but not the intensity. A recent
study showed that the behavioral cutoff score (with the CPOT) was effective in detecting
moderate-to-severe pain, but it could not detect mild levels of pain.25 Therefore, a behavioral
score should not be considered equivalent to a self-report of pain intensity.10
Studies using the BPS and the CPOT in ICUs showed improved routine assessments of pain and
better use of analgesic agents and sedatives, as well as a decrease in the duration of mechanical
ventilation and the number of nosocomial infections.26-29 These behavioral pain scales can be
implemented with minimal standardized training.

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Avoid the use of vital signs as a primary assessment for pain.

Vital signs (eg, blood pressure, heart rate, respiratory rate) should never be used as the sole
indicator of pain; rather, they should be considered cues to begin further pain assessment and
avoid potential adverse effects of untreated pain.9-10
Vital signs are easily accessible in ICUs, and nurses consider them important in pain assessment.
(A large Canadian survey reported that more than 70% of ICU nurses used vital signs to assess
pain.30) However, current evidence does not support the validity of vital signs to detect pain in
critically ill adults. Values of vital signs were found to increase, decrease, or remain stable
during painful procedures.14,21,31-34 Moreover, correlations of vital sign fluctuations with
behavioral pain scores and self-reports of pain were weak or absent.13,19,21,35
Ask someone who knows the patient well about pain behavior.

Proxy reports by someone who knows a patient well can assist nurses in identifying less obvious
changes in behavior that may indicate the presence of pain.10 However, family members tend to
overestimate pain intensity when compared with patients self-reports.36-37 Proxy assessments of
pain should be combined with other evidence, including direct observation with the support of
validated behavioral pain scales, and the presence of known or potentially painful conditions.10
*AACN Levels of Evidence
Level A Meta-analysis of quantitative studies or meta-synthesis of qualitative studies with
results that consistently support a specific action, intervention, or treatment (including
systematic review of randomized controlled trials)
Level B Well-designed, controlled studies with results that consistently support a specific
action, intervention, or treatment
Level C Evidence from qualitative, systematic reviews of qualitative, descriptive or
correlational studies, or randomized controlled trials with inconsistent results
Level D Peer-reviewed professional organizational standards with clinical studies to support
recommendations
Level E Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed
professional organizational standards without clinical studies to support
recommendations
Level M Manufacturers recommendations only
Need More Information or Help?
Contact an AACN clinical practice specialist for additional information at
http://www.aacn.org > Clinical Practice > Practice Resource Network > Ask the
Clinical Practice Team.
Access a free educational video to learn more about using the CPOT in the ICU at
http://pointers.audiovideoweb.com/stcasx/il83win10115/CPOT2011WMV.wmv/play.asx. Funded and created by Kaiser Permanente Northern California
Nursing Research.
American Society of Pain Management Nursing position statement on pain
assessment in patients who cannot self-report: Herr K, Coyne PJ, McCaffery M,
Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position
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statement with clinical practice recommendations. Pain Manag Nurs.


2011;12(4):230-250.
Glinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the
critical-care pain observation tool on pain assessment/management nursing practices
in an intensive care unit with nonverbal critically ill adults: a before and after study.
Int J Nurs Stud. 2011;48(12):1495-1504. Appendix A contains a description of and
directives on the use of the CPOT.
Chanques G, Jaber S, Barbotte E, et al. Impact of systematic evaluation of pain and
agitation in an intensive care unit. Crit Care Med. 2006;34(6):1691-1699. Appendix 1
contains a description of the use of the BPS.
Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St
Louis, MO: MosbyElsevier; 2010.

Approved by AACN Evidence-Based Practice Resources Work Group, May 2013

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References
1. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of
pain at rest: incidence and characteristics of an unrecognized symptom in surgical and
trauma versus medical intensive care unit patients. Anesthesiology. 2007;107(5):858-860.
2. Puntillo KA, White C, Morris AB, et al. Patients perceptions and responses to procedural
pain: results from Thunder Project II. Am J Crit Care. 2001;10(4):238-251.
3. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention.
Lancet 2006;367(9522):1618-1625.
4. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and
chronic persistent postoperative pain. Anesthesiol Clin North America. 2005;23(1):21-36.
5. Dunwoody CJ, Krenzischek DA, Pasero C, Rathmell JP, Polomano RC. Assessment,
physiological monitoring, and consequences of inadequately treated acute pain. J
Perianesth Nurs. 2008:23(suppl 1), S15-S27.
6. Kastrup M, von Dossow V, Seeling M, et al. Key performance indicators in intensive care
medicine. A retrospective matched cohort study. J Int Med Res. 2009;37(5):1267-1284.
7. Loeser JD, Treede, RD. The Kyoto protocol of IASP Basic Pain Terminology. Pain.
2008;137(3):473-477.
8. Shannon K, Bucknall T. Pain assessment in critical care: what have we learnt from
research. Intensive Crit Care Nurs. 2003;19(3):154-162.
9. Barr J, Fraser GL, Puntillo KA, et al. Clinical practice guidelines for the management of
pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med.
2013;41(1):263-306.
10. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient
unable to self-report: position statement with clinical practice recommendations. Pain
Manag Nurs. 2011;12(4):230-250.
11. Chanques G, Viel E, Constantin JM, et al. The measurement of pain in intensive care unit:
comparison of 5 self-report intensity scales. Pain. 2010;151(3):711-721.
12. Glinas C. Le thermomtre dintensit de douleur: un nouvel outil pour les patients adultes
en soins critiques [The Faces Pain Thermometer: a new assessment tool for critically ill
adults]. Perspect Infirm. 2007;4(4):12-20.
13. Glinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of
the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain.
2007;23(6):497-505.
14. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using
a behavioral pain scale. Crit Care Med. 2001;29(12):2258-2263.
15. Glinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain
observation tool in adult patients. Am J Crit Care. 2006;15(4):420-427.
16. Glinas C, Puntillo KA, Joffe A, Barr JA. A validated approach to evaluating
psychometric properties of pain assessment tools for use in nonverbal critically ill adults.
Semin Respir Crit Care Med. 2013;34(2):153-168.
17. Ahlers SJ, van Gulik L, van der Veen AM, et al. Comparison of different pain scoring
systems in critically ill patients in a general ICU. Crit Care. 2008;12(1):R15.

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18. Ahlers SJ, van der Veen AM, van Dijk M, Tibboel D, Knibbe CA. The use of the
Behavioral Pain Scale to assess pain in conscious sedated patients. Anesth Analg.
2010;110(1):127-133.
19. Assaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral
pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg.
2005;101(5):1470-1476.
20. Chen YY, Lai YH, Shun SC, Chi NH, Tsai PS, Liao YM. The Chinese Behavior Pain
Scale for critically ill patients: translation and psychometric testing. Int J Nurs Stud.
2011;48(4):438-448.
21. Glinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive
procedure in conscious and unconscious mechanically ventilated adults: similar or
different? J Crit Care. 2009;24(4):628.e7-628.e17.
22. Juarez P, Bach A, Baker M, et al. Comparison of two pain scales for the assessment of
pain in the ventilated adult patient. Dimens Crit Care Nurs. 2010;29(6):307-315.
23. Nrnberg Damstrm D, Saboonchi F, Sackey PV, Bjrling G. A preliminary validation of
the Swedish version of the Critical-Care Pain Observation Tool in adults. Acta
Anaesthesiol Scand. 2011;55(4):379-386.
24. Vazquez M, Pardavila MI, Lucia M, Aguado Y, Margall MA, Asiain MC. Pain
assessment in turning procedures for patients with invasive mechanical ventilation. Nurs
Crit Care. 2011;16(4):178-185.
25. Glinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the
critical-care pain observation tool for the detection of pain in intubated adults after
cardiac surgery. J Pain Symptom Manage. 2009;37(1):58-67.
26. Chanques G, Jaber S, Barbotte E, et al. Impact of systematic evaluation of pain and
agitation in an intensive care unit. Crit Care Med. 2006;34(6):1691-1699.
27. Glinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the
critical-care pain observation tool on pain assessment/management nursing practices in
an intensive care unit with nonverbal critically ill adults: a before and after study. Int J
Nurs Stud. 2011;48(12):1495-1504.
28. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J, DOLOREA Investigators. Pain
assessment is associated with decreased duration of mechanical ventilation in the
intensive care unit: a post Hoc analysis of the DOLOREA study. Anesthesiology.
2009;111(6):1308-1316.
29. Rose L, Haslam L, Dale C, Knechtel L, McGillion M. Behavioral pain assessment tool
for critically ill adults unable to self-report pain. Am J Crit Care. 2013;22(3):246-255.
30. Rose L, Smith O, Glinas C, et al. Critical care nurses pain assessment and management
practices: a survey in Canada. Am J Crit Care. 2012;21(4):251-259.
31. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, et al. Pain related to tracheal
suctioning in awake acutely and critically ill adults: a descriptive study. Intensive Crit
Care Nurs. 2008;24(1):20-27.
32. Siffleet J, Young J, Nikoletti S, Shaw T. Patients self-report of procedural pain in the
intensive care unit. J Clin Nurs. 2007;16(11):2142-2148.
33. Stotts NA, Puntillo K, Bonham MA, et al. Wound care pain in hospitalized adult patients.
Heart Lung. 2004;33(5):321-332.

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34. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to assess pain
in ventilated, unconscious and/or sedated patients. Intensive Crit Care Nurs.
2006;22(1):32-39.
35. Arbour C, Glinas C. Are vital signs valid indicators for the assessment of pain in
postoperative cardiac surgery ICU adults? Intensive Crit Care Nurs. 2010;26(2):83-90.
36. Kappesser J, Williams AC, Prkachin KM. Testing two accounts of pain underestimation.
Pain. 2006;124(1-2):109-116.
37. Puntillo KA, Neuhaus J, Arai S, et al. Challenge of assessing symptoms in seriously ill
intensive care unit patients: can proxy reporters help? Crit Care Med. 2012;40(10):27602767.

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