Assessing Pain in the Critically Ill Adult

Scope and Impact of the ProblemMany 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 andthe 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 assessmenttools.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 assessmentsduring patient handoffs.

2. Perform a pain assessment for critically ill adults who are unable to self-report, using avalidated behavioral pain scale, such as the Behavioral Pain Scale (BPS) or the Critical-Care 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 EvidenceAttempt 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 adultpatients 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, aself-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 EvidenceLevel A Meta-analysis of quantitative studies or meta-synthesis of qualitative studies with

results that consistently support a specific action, intervention, or treatment (includingsystematic 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/CPOT2011-WMV.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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References1. 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.

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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.

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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.

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21. Glinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar ordifferent? 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.

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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.

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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.

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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.

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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