P

ain is an important problem in the intensive care unit (ICU), and inadequate pain
assessment and management have been linked to increased morbidity and mortal-
ity.
1
The physiological response to pain is almost universally adverse, causing poten-
tially fatal unstable hemodynamic status, alterations in immune system functioning,
hyperglycemia, and increased release of catecholamine, cortisol, and antidiuretic hor-
mones.
2
Moreover, uncontrolled pain has been implicated in a variety of psychosocial effects,
including depression, anxiety, delirium, posttraumatic stress disorder, and disorientation.
3
Despite
the acknowledgment that pain is a common stressor in the ICU,
4
high rates of uncontrolled pain in
critically ill patients remain common.
5
This situation can be attributed, in part, to circumstances,
such as mechanical ventilation or unstable hemodynamic status, that preclude the assessment of
pain by self-report. Despite strong evidence that documentation of pain assessment improves pain
management and decreases patients pain, no pain assessment instrument has been universally
recommended for use in critically ill patients incapable of self-reporting.
6
Observational Pain Scales
in Critically Ill Adults
Mindy Stites, RN, MSN, APRN, ACNS-BC, CCNS, CCRN
2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013804
Pain Management
Pain is a common and distressing symptom in critically ill patients. Uncontrolled pain places patients at risk
for numerous adverse psychological and physiological consequences, some of which may be life-threatening.
A systematic assessment of pain is difficult in intensive care units because of the high percentage of patients
who are noncommunicative and unable to self-report pain. Several tools have been developed to identify objec-
tive measures of pain, but the best tool has yet to be identified. A comprehensive search on the reliability and
validity of observational pain scales indicated that although the Critical-Care Pain Observation Tool was supe-
rior to other tools in reliably detecting pain, pain assessment in individuals incapable of spontaneous neuro-
muscular movements or in patients with concurrent conditions, such as chronic pain or delirium, remains an
enigma. (Critical Care Nurse. 2013;33[3]:68-79)
This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:
1. Describe the impact of uncontrolled pain on critically ill patients
2. Identify 2 validated pain scales for critically ill patients
3. Describe instrument reliability and validity when considering pain scales for critically ill patients
CNE Continuing Nursing Education
68 CriticalCareNurse Vol 33, No. 3, JUNE 2013 www.ccnonline.org
Background and Significance
The pathophysiology of pain is complex, but involves
the release of inflammatory mediators after tissue injury.
The mediators stimulate nociceptors, which transmit
pain impulses to the dorsal horn of the spinal cord. The
pain impulses arrive at the somatosensory cortex, where
the localization and meaning of pain occur.
7
Pain can be
classified as acute or chronic, depending on duration, and
as peripheral or central, depending on location. Further
classifications are used to describe the pain source, such
as from injury to the skin (cutaneous), nerves (neuro-
pathic), muscles and bones (somatic), or organs (visceral).
8
Nearly 5 million patients are admitted to the ICU each
year,
9
and an estimated 71% of those patients remember
experiencing pain during their stay.
10
Painful procedures,
such as turning and tracheal suctioning, are common in
the ICU and precipitate acute pain.
11
In addition, many
critically ill patients have a history of chronic pain, which
complicates assessment and treatment.
12
Pain is one of
the most common symptoms in critically ill patients and
is experienced by each patient in a unique manner.
13
The routine use of an appropriate assessment of
pain has been mandated by the Agency for Healthcare
Research and Quality and the Joint Commission.
14
Pro-
fessional organizations such as the American Association
of Critical-Care Nurses, the American College of Chest
Physicians, the Society for Critical Care Medicine, and
the American Society for Pain Management agree. All
of these organizations advocate for implementation of
standardized pain assessment tools that include behav-
ioral indicators in patients who are sedated and receiving
mechanical ventilation and incapable of self-reporting
or whose self-reports may be unreliable.
15
Furthermore,
studies have indicated that appropriate treatment of
pain and anxiety is associated with decreased duration of
mechanical ventilation (8 vs 11 days; P < .01),
16
decreased
rate of nosocomial infections,
4
and increased patient sat-
isfaction with pain control.
14
Additionally, systematic
pain assessment in critically ill patients can decrease
ICU length of stay (13 vs 18 days; P < .01).
16
OVID, PubMed, Medline, and CINAHL databases
were used to search the literature. The key words pain,
assessment, tool, instrument, scale, intensive care, criti-
cal care, and critically ill were used. Articles published
between 2000 and 2010 and available in English were
included in the review. Additional inclusion criteria
included publication in a professional, scholarly, peer-
reviewed nursing and health care journal. Articles that
focused on
infants and
children,
addressed
pain assess-
ment outside the ICU, or focused on the evaluation of
chronic pain were excluded. A total of 1120 articles were
found; of these, 17 met the inclusion criteria. A few
studies are included that did not meet every inclusion
criterion but did contain important information.
Review of the Literature
The review focuses on tools developed for and tested
in adult critical care patients. These instruments include
the Pain Assessment and Intervention Notation (PAIN)
algorithm, the Nonverbal Pain Assessment Tool (NPAT),
the Adult Nonverbal Pain Scale (NVPS), the Behavioral
Pain Scale (BPS), and the Critical-Care Pain Observation
Tool (CPOT).
PAIN Algorithm
The PAIN algorithm,
17
developed in 2001, consists
of 3 parts: pain assessment, the ability of the patient to
tolerate opioids, and guidelines for analgesic treatment
decisions and documentation. The pain assessment sec-
tion of the tool contains both behavioral (movement,
facial cues, posturing) and physiological (increased heart
rate, respiratory rate, and blood pressure and perspiration
or pallor) dimensions.
The initial testing of the tool included a study sample
of 11 nurses who used the instrument to assess 31 post-
operative patients in the ICU or postanesthesia care unit.
17
The algorithm was helpful in providing a systematic
approach to pain assessment and guidance of analgesic
administration. However, 4 of the 11 nurses thought that
the PAIN tool was not helpful: it was too long and cum-
bersome to be used in everyday practice. Reliability
Author
Mindy Stites is a critical care clinical nurse specialist at the University
of Kansas Hospital, Kansas City, Kansas, and a recent graduate of the
University of Missouri, Sinclair School of Nursing, Columbia, Missouri.
Corresponding author: Mindy Stites, RN, MSN, APRN, ACNS-BC, CCNS, CCRN, 231 Edgewood
Dr, Wellsville KS, 66092 (e-mail: mindystites@gmail.com).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia,
Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949)
362-2049; e-mail, reprints@aacn.org.
www.ccnonline.org CriticalCareNurse Vol 33, No. 3, JUNE 2013 69
Of the nearly 5 million patients admitted to the
ICU each year, an estimated 71% remember
experiencing pain during their stay.
and validity of the tool were not determined. Although
the researchers found that the instrument could be a
useful training technique for beginning ICU nurses, the
length of the tool has limited its clinical usefulness, and
no further testing has been done.
17
Nonverbal Pain Assessment Tool
The NPAT consists of 5 domains: emotion, movement,
verbal cues, facial cues, and positioning/guarding.
10
Two
separate scoring systems are provided on the instru-
ment for use in both verbal and nonverbal patients.
Scores range from 0 to 10 points, with higher numbers
indicating higher severity of pain. The initial testing of
the NPAT consisted of 3 phases of validity testing and 2
revisions of the tool. In the third phase of validity test-
ing, the investigators analyzed the correlation between
the NPAT score and the patients self-reported pain
score in a sample of 50 general medical-surgical, post-
operative patients.
Interrater reliability was high (concordance coefficient,
0.72; 95% confidence interval), and criterion validity
(Table 1) was moderately strong when the NPAT was com-
pared with the gold standard of self-report (concordance
coefficient, 0.66; 95% confidence interval).
10
Although
designed for noncommunicative critically ill patients,
the NPAT has not been validated in this population of
patients; the initial testing of the third phase was done in
verbal medical-surgical patients. In addition, the inclu-
sion of a verbal cues domain in a nonverbal pain
assessment tool is perplexing. Previous versions of the
NPAT studied in the ICU showed weak validity (concor-
dance correlation coefficient, 0.31; 95% confidence inter-
val and concordance correlation coefficient, 0.21; 95%
confidence interval, respectively). Since the initial testing
in 2010, no further reliability or validity testing of the
NPAT has been completed.
19
Adult Nonverbal Pain Scale
The NVPS (Table 2) was based on the Faces, Legs,
Activity, Cry, Consolability (FLACC) scale.
20
Like the PAIN
algorithm and the NPAT, the NVPS contains behavioral
dimensions (facial expression, activity, and guarding)
and physiological dimensions (heart rate, blood pressure,
and respiratory rate) that are graded in severity. The final
domain of the NVPS includes autonomic indicators such
as dilated pupils, diaphoresis, flushing, or pallor. Each
domain is ranked from 0 to 2, with a total score between
0 (no pain) and 10 (maximum pain).
The initial testing of the NVPS was conducted in a
burn trauma unit on 59 patients, with a total of 100
paired assessments performed. Internal consistency was
high (=.78; P<.001). The authors
20
concluded that the
NVPS was a valid observational pain scale in this patient
population because correlation of the NVPS scores with
the FLACC scores was high (= 86; P=.05). However,
use of the FLACC as a gold standard in this study cannot
be supported; the FLACC was developed for use in chil-
dren and has not been validated in adults.
Research term
Construct validity
Content validity
Criterion validity
Discriminant validity
Interrater reliability
Internal consistency
Sensitivity
Specificity
Definition
a
The degree to which an instrument measures the construct under investigation
The degree to which the items in an instrument adequately represent the universe of content for the concept
being measured
The degree to which scores on an instrument are correlated with some external criterion
An approach used to construct validation that involves assessing the degree to which a single method of
measuring 2 distinct constructs yields different results (ie, the presence or absence of pain)
The degree to which 2 raters or observers, operating independently, assign the same ratings or values for an
attribute being measured or observed
The degree to which the subparts of an instrument are all measuring the same attribute or dimension, as a
measure of the instruments reliability
The ability of screening instruments to correctly identify a case, that is, to correctly diagnose a condition
The ability of a screening instrument to correctly identify noncases
Table 1 Terms used in testing instrument reliability and validity
a
Definitions from Polit and Beck.
18
70 CriticalCareNurse Vol 33, No. 3, JUNE 2013 www.ccnonline.org
In a study by Kabes et al,
21
a revised version of the
NVPS was compared with the original NVPS for reliabil-
ity and validity testing. The revised NVPS includes a new
respiratory category that replaces the physiological II
dimension of the original scale.
22
The dimension includes
an assessment of the amount of deviation from the base-
line respiratory rate, as well as oxygen saturation as meas-
ured by pulse oximetry and level of compliance with the
ventilator. Using a nonexperimental design, nurses in a
trauma-surgical ICU assessed patients before, during, and
at rest after a painful nursing procedure.
The levels of interrater reliability (90% in 94.7% with
original NVPS and 90.8% with the revised NVPS) and
internal consistency (Cronbach , 0.36 before, 0.72 dur-
ing, 0.71 after) were high. Both the original and the revised
NVPS showed significant differences between ratings
before, during, and after the painful procedure (original,
135.86; P<.001; n=121; revised, 145.05; P<.001; n=121).
21
Correlations between NVPS scores and self-report scores
were not determined.
Marmo and Fowler
23
used a repeated-measures study
design to examine the validity of the NVPS in a sample
of 25 critically ill patients after open
heart surgery. The NVPS, CPOT,
and FLACC were administered for
a total of 300 paired, independent
observations before, during, and
after a painful procedure (endotra-
cheal suctioning, turning). The
NVPS was reliable, with a Cron-
bach coefficient of 0.89, but dis-
agreement was high between nurse
raters in analyses of the facial expres-
sion dimension (25% of the total
observations).
Wibbenmeyer et al
24
did a simi-
lar study in a sample of 38 burn
patients. A total of 225 paired assess-
ments were completed by nursing
staff who were briefly educated
on use of the CPOT and the NVPS.
No description of the education was
provided. The assessments were
completed with the patients at rest
and again shortly after a painful
stimulus (wound care, physical or
occupational therapy). Because all
of the patients were able to respond verbally, a self-
report of pain intensity was also obtained. The NVPS
had good internal consistency (Cronbach = 0.80), but
interrater reliability was merely fair (Pearson correlation
coefficient, 0.59). The poor reliability may have been
due to the limited education of the data collectors on
the appropriate administration of the tool. Discriminate
validity was indicated by the change in mean NVPS
scores beginning with a mean at-rest score of 0.19 and
increasing to 0.44 (P<.001) after the noxious stimulus
was applied. Correlation between the NVPS and the
Numerical Rating Scale (NRS) was poor (Pearson corre-
lation coefficient, 0.38; P<.01), indicating that the NVPS
is a poor indicator of pain intensity.
Finally, Topolovec-Vranic et al
25
found that implemen-
tation of the NVPS was associated with a trend toward
decreased levels of severe pain (55% vs 35% of patients
reporting severe pain), although these findings were not
statistically significant, and increased frequency of pain
assessment (29% vs 59%; P < .001). The investigators
25
acknowledged that the trend may have been due to an
increased awareness of the need to assess pain after the
Table 2 Adult Nonverbal Pain Scale
Abbreviations: HR, heart rate; RR, respiratory rate; SBP, systolic blood pressure; SpO
2
, pulse oximetry.
Instructions: Each of the 5 categories is scored from 0-2, which results in a total score between 0 and 10.
Document total score by adding numbers from each of the 5 categories. Scores of 0-2 indicate no
pain, 3-6 moderate pain, and 7-10 severe pain. Document assessment every 4 hours on nursing flow-
sheet and complete assessment before and after intervention to maximize patient comfort. Sepsis,
hypovolemia, hypoxia need to be excluded before interventions.
Strong Memorial Hospital, University of Rochester Medical Center, 2004. Used with permission.
Categories
Face
Activity
(movement)
Guarding
Physiology
(vital signs)
Respiratory
0
No particular
expression or
smile
Lying quietly,
normal position
Lying quietly, no
positioning of
hands over
areas of body
Stable vital signs
Baseline RR/SpO
2
Compliant with
ventilator
1
Occasional grimace,
tearing, frowning,
wrinkled forehead
Seeking attention
through movement
or slow, cautious
movement
Splinting areas of the
body, tense
Change in any of the
following:
* SBP>20 mm Hg
* HR>20/min
RR >10 above baseline,
or 5% SpO
2
mild
asynchrony with
ventilator
2
Frequent grimace,
tearing, frowning,
wrinkled forehead
Restless, excessive
activity and/or
withdrawal reflexes
Rigid, stiff
Change in any of the
following:
* SBP>30 mm Hg
* HR>25/min
RR >20 above baseline,
or 10% SpO
2
severe
asynchrony with
ventilator
www.ccnonline.org CriticalCareNurse Vol 33, No. 3, JUNE 2013 71
NVPS education sessions that were
provided to the staff before the data
collection period.
Behavioral Pain Scale
The BPS
26
(Table 3) was based
on the work of Puntillo et al
27
that
identified unique behaviors present
in patients undergoing a noxious
stimulus. The BPS is composed of 3
observational items (facial expression,
upper limbs, and compliance with
ventilation) that are scored from 1
to 4, with higher numbers indicat-
ing higher levels of discomfort. The
total BPS score can range from 3 (no
pain) to 12 (most pain). The BPS was initially tested by
using a quasi-experimental design and a sample of 30
patients receiving mechanical ventilation.
26
The BPS scores
were assessed at rest and then during a nonpainful pro-
cedure (application of compression stockings or dressing
change of a central venous catheter) or during a nocicep-
tive procedure (endotracheal suctioning or turning).
Patients who had painful procedures had higher BPS
scores (range, 4.6-5.2) than did patients who had non-
painful procedures (BPS score range, 3.3-3.7). A test-retest
procedure was then performed in 31 cases, resulting in
BPS scores that increased from 3.0 to 3.3 at rest to 4.0
to 4.8
during a
painful
procedure,
establish-
ing construct validity. Interrater agreement was high
( = 0.94), and 24 of the 28 evaluators reported that
the BPS was easy to use and took a mean of 2 to 5 min-
utes to complete.
Assaoui et al
28
tested the BPS in 30 general ICU
patients in a total of 360 observations. All patients
included in the study were sedated and were receiving
mechanical ventilation. In paired, independent observa-
tions, BPS scores were obtained at rest and during painful
procedures (endotracheal suctioning or peripheral vein
cannulation). The BPS had good internal consistency
(Cronbach = 0.72), and interrater agreement was high
(intraclass correlation coefficient, 0.95). Validity was
established by the change in BPS scores (mean, 3.9; SD,
1.1 at rest and mean, 6.8; SD, 1.9 during procedures).
The elevated BPS scores at rest are interesting and most
likely support hypotheses provided in previous research
that critically ill patients may have moderate levels of
pain even at rest.
29
In another study, Young et al
30
used a descriptive,
repeated-measures design to analyze the reliability and
validity of the BPS. A total of 44 patients receiving
mechanical ventilation whose hemodynamic status was
stable were assessed before and after a nonpainful (eye
care) and a painful (repositioning) procedure. The mean
BPS score increased significantly after the repositioning
procedure (score, 3.36 before vs 5.02 after). In contrast,
the mean BPS score did not change significantly after
the eye care procedure (score, 3.23 before vs 3.38 after),
supporting discriminate validity of the BPS. However,
interrater agreement varied widely, with good agreement
(82%-91%) during rest states, but a marked decrease in
agreement after a painful procedure (36%-46%). These
results indicate that raters more easily agreed on the level
of pain when the level was low and that variance between
raters occurred when pain levels were high.
Ahlers et al
31
obtained 371 independent determinations
of the BPS and NRS (when possible) in 113 critically ill
patients. The BPS was completed for all patients receiv-
ing mechanical ventilation; the NRS was either estimated
by the bedside nurse or obtained from the patient if the
patient was able to respond. Having a bedside nurse
estimate the NRS score is a questionable practice, because
this study
31
indicated that the NRS score as reported by
the patient correlated with the score estimated by the
Table 3 Behavioral Pain Scale
Item
Facial expression
Upper limb movements
Compliance with mechanical
ventilation
Score
a
1
2
3
4
1
2
3
4
1
2
3
4
Description
Relaxed
Partially tightened (eg, brow lowering)
Fully tightened (eg, eyelid closing)
Grimacing
No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
Tolerating movement
Coughing but tolerating ventilation for
most of the time
Fighting ventilator
Unable to control ventilation
a
Score ranges from 3 (no pain) to 12 (maximum pain).
72 CriticalCareNurse Vol 33, No. 3, JUNE 2013 www.ccnonline.org
Although designed for noncommunicative
critically ill patients, the NPAT has not been
validated in this population of patients.
nurse only 73% of the time. Despite the problematic study
design, the interrater reliability of the BPS was good
( = 0.67; 95% CI, 0.54-0.80). Of note, NRS scores were
0 in only 5% of the observations, whereas BPS scores
were 3, indicating no pain, in 68%. These data illuminate
an interesting question in the study by Payen et al
26
in
which the proportion of low BPS scores at rest was high.
Possibly a BPS score of 3 is not truly representative of a
pain-free state as previously postulated. In addition, the
BPS equates lack of body movement with a pain-free state,
which conflicts with research
32
that indicates a correlation
between decreased movement and increased pain levels.
In a follow-up study, Ahlers et al
33
examined the reli-
ability and validity of the BPS in both deeply sedated
patients and patients undergoing conscious sedation for
a painful procedure. Nurses made 175 observations in a
convenience sample of 80 medical-surgical ICU patients
at 4 times: at rest, during a nonpainful procedure, dur-
ing a painful procedure, and after the painful procedure.
The assessments were done independently, and commu-
nicative patients were asked to provide a report of their
pain intensity by using the Verbal Rating Scale 4
29
if able
to do so after the BPS scoring was completed. Interrater
reliability of the BPS was excellent (=0.80 for deeply
sedated patients and 0.83 for conscious sedated patients).
Internal consistency was moderate (=0.63 in deeply
sedated patients and 0.66 in conscious sedated patients).
BPS scores were higher during painful procedures than
at rest in both deeply sedated patients (mean, 5.1; 95%
CI, 4.8-5.5 vs mean, 3.4; 95% CI, 3.3-3.5) and conscious
sedated patients (mean, 5.4; 95% CI, 4.9-5.9 vs mean, 3.8;
95% CI, 3.5-4.1), thus establishing construct validity.
The BPS and the Verbal Rating Scale 4 had a strong pos-
itive correlation during painful procedures (r=0.67;
P<.001), indicating that the BPS is a valid tool to be used
in both deeply sedated and moderately sedated patients.
Critical-Care Pain Observation Tool
The CPOT
34
(Table 4) was developed on the basis of
retrospective chart reviews to determine common pain
notations and findings with focus groups of ICU clinicians.
This instrument is designed for use in both intubated and
nonintubated critical care patients. Four domainsfacial
expressions, movements, muscle tension, and ventilator
complianceare scored from 0 to 2; total scores range
from 0 (no pain) to 8 (most pain). The CPOT contains
Indicator
Facial expression
Body movements
Muscle tension
Evaluation by passive flexion and
extension of upper extremities
Compliance with the ventilator
(intubated patients)
OR
Vocalization (extubated patients)
Total, range
Description
No muscular tension observed
Presence of frowning, brow lowering, orbit tightening,
and levator contraction
All of the above facial movements plus eyelid tightly
closed
Does not move at all (does not necessarily mean
absence of pain)
Slow, cautious movements, touching or rubbing the
pain site, seeking attention through movements
Pulling tube, attempting to sit up, moving limbs/
thrashing, not following commands, striking at
staff, trying to climb out of bed
No resistance to passive movements
Resistance to passive movements
Strong resistance to passive movements, inability
to complete them
Alarms not activated, easy ventilation
Alarms stop spontaneously
Asynchrony: blocking ventilation, alarms frequently
activated
Talking in normal tone or no sound
Sighing, moaning
Crying out, sobbing
Score
Relaxed, neutral 0
Tense 1
Grimacing 2
Absence of movements 0
Protection 1
Restlessness 2
Relaxed 0
Tense, rigid 1
Very tense or rigid 2
Tolerating ventilator or movement 0
Coughing but tolerating 1
Fighting ventilator 2
Talking in normal tone or no sound 0
Sighing, moaning 1
Crying out, sobbing 2
0-8
Table 4 Critical-Care Pain Observation Tool
www.ccnonline.org CriticalCareNurse Vol 33, No. 3, JUNE 2013 73
evidence-based descriptors that are operationally defined
for each domain, and the content validity index of all
indicators was 0.88 to 1.0, according to an analysis of the
results of a questionnaire provided to physicians and
critical care nurses. The CPOT was originally developed
in French and was tested in a convenience sample of 105
cardiac surgery patients.
Glinas et al
35
used a repeated-measures design and
trained data collectors to obtain the CPOT score of 105
patients at 3 times: at rest, immediately after reposition-
ing (nociceptive procedure), and at recovery (20 minutes
after repositioning). After completion of the assessment
by 2 observers, the patient was asked to indicate the
presence or absence of pain by nodding the head yes or
no. Patients who had delirium (as indicated by the Con-
fusion Assessment Method for the Intensive Care Unit)
were excluded from the study. Interrater reliability was
moderate to high (weighted coefficient =0.52-0.88)
when tested between the same 2 data collectors. Crite-
rion validity was established by comparing the patients
self-report of pain and the concurrent CPOT score. In
patients reporting pain, the mean CPOT score was 1.62
to 3.65; in patients reporting no pain, the mean score was
0.49 to
2.11.
Although
the mean
CPOT
scores were lower in the patients reporting no pain, the
CPOT appeared to provide an overestimation of pain in
some instances, especially in the immediate period after
a nociceptive procedure (mean, 2.11; SD, 0.90). Discrim-
inate validity was supported by the finding that the CPOT
scores were significantly higher (P < .001) during posi-
tioning (t = -15.96) than at rest (t = -9.01). Although the
study sample was large, interrater reliability and the
homogeneity of the sample were acknowledged limitations.
In a post hoc data analysis, Glinas et al
36
evaluated
the sensitivity and specificity of the CPOT. They found
that the tool had a sensitivity of 86% and a specificity of
78% during painful procedures. However, the sensitivity
decreased to 83% before a painful procedure and was 63%
after the procedure. Specificity remained high at 83%
and 97%, respectively. A cross-over observational design
was used to test the first English version of the CPOT in
a group of 30 conscious and 25 unconscious general ICU
patients.
37
Additional data were collected in this study,
37
including physiological data and patients self-report of
pain via use of the Faces Pain Thermometer. Interrater
reliability was acceptable (intraclass correlation coeffi-
cients, 0.80-0.93) among the 51 nurses who collected the
data. Discriminate validity was established by detection
of elevations in heart rate and blood pressure that occurred
in accordance with elevated CPOT scores. Yet, physical
motion is known to increase heart rate and blood pressure
to compensate for increased oxygen demand, making
this method of establishing validity problematic. How-
ever, when patients self-reported pain values were com-
pared with the observer-derived CPOT scores, the positive
predictive value of the CPOT was high (85.7%). All of the
nurse respondents reported that the CPOT directives
were clear and that the tool was easy to use. The major-
ity of the nurses also reported that the CPOT was quick
to use (78%) and that they would recommend use of the
CPOT routinely in practice (72.7%).
38
Marmo and Fowler
23
tested the CPOT in patients after heart surgery and
found that the tool had high reliability ( = 0.89). These
researchers
23
were also the first to report the internal con-
sistency of the CPOT (56%-100% agreement). The CPOT
was also included in the previously discussed study by
Wibbenmeyer et al,
24
who reported a high internal con-
sistency (Cronbach , 0.71) and good discriminate valid-
ity (mean scale scores = 0.27 at rest to 0.56 after noxious
stimulation). As with the NVPS, Wibbenmeyer et al
reported that the interrater reliability of the CPOT was
poor (Pearson correlation coefficient, 0.63; P<.001).
However, this poor reliability could again be due to the
limited amount of training the assessors received before
data collection. In the study by Marmo and Fowler,
23
an
85% agreement between raters was ensured before the
study began. In the study by Wibbenmeyer et al,
24
inter-
rater agreement was not optimized before data collection.
Vzquez et al
39
conducted a prospective, repeated-
measures study in a 12-bed general ICU in Spain. A total
of 330 paired observations were completed in a study
sample of 96 critically ill patients. Observations were
conducted before, during, and after a repositioning pro-
cedure. Interrater reliability of the CPOT was excellent
(=0.79), and discriminate validity was good; mean
scores were 0.27 (SD, 0.64) at rest and 1.93 (SD, 1.41)
during the procedure.
Finally, Glinas et al
40
examined the effects of imple-
menting the CPOT in a general ICU in Canada. Before
implementation, interrater agreement for patients at rest
74 CriticalCareNurse Vol 33, No. 3, JUNE 2013 www.ccnonline.org
Interestingly, implementation of the CPOT
was associated with decreased frequency of
administration of sedatives and analgesics.
was high (95%-100%), and agreement during turning was
acceptable (73%-91%). After implementation of the CPOT,
interrater agreement improved to 86% to 100%. When
pain assessment practices were analyzed by using descrip-
tive statistics, reports of pain assessments were 3 to 4
times more frequent after implementation than they
were before implementation. Interestingly, implementa-
tion of the CPOT was associated with decreased frequency
of administration of sedatives and analgesics. Glinas et
al
40
provide 2 possible explanations: increased ability of
nursing staff to discern pain from other symptoms (such
as anxiety) or decreased number of trauma patients in
the group after implementation because of a change in
the centers trauma designation.
Analysis of the Literature
The published evidence indicates that more research
to find the ideal instrument to assess pain in critically ill
nonverbal adults is needed. Although multiple tools are
available, few have been reliable and valid across a multi-
tude of patient populations and settings (Table 5). How-
ever, some tools clearly have been tested much more
than others have. The PAIN algorithm and NPAT have
each been used in only a single study, and the findings
in both studies were of limited value. The original test-
ing of the NVPS is of limited value because of the studys
nonexperimental design and the use of the FLACC scale
as the gold standard for comparison. Although the NVPS
is the only tool that includes dimensions of physiological
data, these indicators have been some of the least sensi-
tive markers for the presence of pain.
41
An overwhelming majority of the studies provide
support for the reliability and validity of both the BPS
and the CPOT in detecting pain in noncommunicative
critically ill adults. The internal consistency and interrater
reliability of both the BPS and the CPOT have been shown
in more than 1 prospective study. However, comparisons
of study findings indicate that the CPOT has been more
internally consistent than the BPS (Cronbach =0.71-
0.89 vs Cronbach =0.63-0.66, respectively). Whether
these data translate into a true implication for practice
remains to be seen; high levels of internal consistency may
simply indicate redundancy within the tool.
42
Moreover,
the range of statistical analyses used in the data analysis
for the CPOT was broader than that used for the BPS.
The results of construct, criterion, and discriminate
validity analyses in a variety of patient populations have
been favorable for both the BPS and the CPOT; both tools
indicated a statistically significant increase in scores after
a painful procedure was performed. However, the stud-
ies by Payen et al
26
and Young et al
30
also indicated an
increase in the BPS score after a nonnociceptive proce-
dure, making the specificity of the instrument a concern.
Although the sensitivity and specificity of the CPOT
have been investigated,
32
no data on sensitivity or speci-
ficity of the BPS have been reported. An interesting find-
ing is the mean at-rest scores, which were elevated with
both tools (BPS score, 3.7; CPOT score, 0.27). These find-
ings suggest baseline pain is present in a majority of crit-
ically ill patients, consistent with the results of a previous
study
29
on characteristics of pain in the ICU.
An important finding of the validity testing of both
tools is a lack of strong correlation of the observational
pain tools with patients self-reports. The correlation was
especially
poor when
patients
were scored
as having no
pain (BPS
score, 3; CPOT score, 0), and only a few patients had no
pain on self-report scales. These findings suggest that
although scores increased during nociceptive proce-
dures, indicating the presence of increased pain, the BPS
and the CPOT may not be useful tools for establishing the
severity of pain. Attempts to validate the tools as a method
of assessing pain severity have not been successful.
41
Summary and Recommendations for
Further Research
In summary, internal consistency and interrater reli-
ability in several studies have indicated the reliability of
both the CPOT, and to a lesser extent, the BPS. Construct
validity of both tools has been indicated in multiple pop-
ulations of patients. However, the CPOT has been tested
in both verbal and nonverbal patients in ICUs, a charac-
teristic that may extend its applicability to practice. In
addition, the evidence indicates that the BPS may lack
specificity in the detection of pain in noncommunicative
critically ill adults, a phenomenon not found in the test-
ing of the CPOT. A comparison of the evidence support-
ing the use of the BPS with that supporting use of the
CPOT suggests that the CPOT may be a more specific,
reliable, tool in nonverbal critically ill patients.
www.ccnonline.org CriticalCareNurse Vol 33, No. 3, JUNE 2013 75
Although multiple observational pain scales
are available, few have been reliable and
valid across a multitude of patient popula-
tions and settings.
Research study
Behavioral Pain Scale (BPS)
Payen et al,
27
2001
Assaoui et al,
28
2005
Young et al,
30
2006
Ahlers et al,
31
2008
Ahlers et al,
33
2010
Critical-Care Pain Observation Tool (CPOT)
Glinas et al,
14
2004
Glinas et al,
35
2006
Glinas and Johnson,
37
2007
Marmo and Fowler,
23
2010
Wibbenmeyer et al,
24
2011
Vzquez et al,
39
2011
Gelinas et al,
40
2011
Nonverbal Pain Scale (NVPS)
Odhner et al,
20
2003
Kabes et al,
21
2009 (revised version)
Marmo and Fowler,
23
2010
Wibbenmeyer et al,
24
2011
Reliability findings
Interrater reliability: 0.94 (Cronbach )
Internal consistency: 0.72 (Cronbach )
Interrater agreement: 0.95 (ICC)
Interrater agreement: 82%-91% at rest,
36%-46% during procedure
Interrater reliability: 0.67 (95% CI,
0.54-0.80)
Interrater reliability: = 0.80-0.83
Internal consistency: Cronbach =
0.63-0.66
Interrater reliability: weighted
coefficient =0.52-0.88
Interrater reliability: 0.80-0.93 (ICC)
Interrater reliability: 0.89 (Cronbach )
Interrater agreement: 56%-100%
Interrater reliability: 0.63, P<.001
(Pearson correlation coefficient)
Interrater reliability = 0.79
Interrater agreement 97%-100%
Interrater agreement:
Before implementation, 73%-91%
After implementation, 86%-100%
Internal consistency: Cronbach =0.78
Interrater agreement: 90%-94.7%
Internal consistency: 0.36-0.71
(Cronbach )
Interrater reliability: Cronbach = 0.89
Interrater agreement: 75% on face dimension
Internal consistency: Cronbach =0.80
Interrater reliability: 0.59 (Pearson
correlation coefficient)
Validity findings
Discriminate validity: Painful procedure
scores (4.6-5.2) compared with nonpainful
procedure scores (3.3-3.7)
Construct validity, test-retest procedure:
BPS score increased from 3.0-3.3 at rest
to 4.0-4.8 during procedure
Construct validity: mean score, 3.9 (SD, 1.1) at
rest and 6.8 (SD, 1.9) during procedures
Construct validity: 3.36 at rest vs 5.02
after painful procedure
Discriminate validity: 3.23 at rest vs 3.38
after nonpainful procedure
Construct validity: moderate correlation (r=0.55,
P<.001, n=57) when nurse-assigned NRS
score compared with BPS score
Construct validity: strong correlation of
VRS-4 and BPS scores (r =0.67, P<.001)
Discriminate validity: 3.4 at rest vs 5.1
during painful procedure
Initial content validity: 0.88-1.0
Criterion validity: patients reporting pain,
CPOT score 1.62-3.65; patients denying
pain, CPOT score 0.49-2.11
Discriminate validity: CPOT scores higher
during painful procedures than at rest
(t =-9.01 to- 15.96, P<.001)
Specificity and sensitivity: painful proce-
dures, 86% and 78%, respectively;
at rest, 83% and 83%, respectively
Positive predictive value of CPOT 85.7% when
compared with self-reported FPT values
No data
Discriminate validity: 0.27 at rest vs 0.56
during stimuli
Discriminate validity: mean score at rest,
0.27 (SD, 0.64); mean score during
procedure, 1.93 (SD, 1.41)
No data
Construct validity: 0.86, (P=.05) when com-
pared with FLACC scores
Discriminate validity:
Original NVPS, 135.86; P<.001; n=122
Revised NVPS, 145.05; P<.001; n=122
No data
Discriminate validity:
Mean score at rest, 0.19
Mean score noxious stimuli, 0.44
Construct validity: correlation of NVPS
and NRS poor, 0.38, (P<.1)
Table 5
Abbreviations: FLACC, Face, Legs, Activity, Cry, Consolability scale; FPT, Faces, Pain, Thermometer scale; ICC, intraclass coefficient; NRS, Numerical Rating Scale;
VRS-4, Verbal Rating Scale 4.
Pain assessment in noncommunicative critically ill
adults remains a work in progress. By design, observa-
tional pain scales require the presence of a spontaneous,
neuromuscular-mediated physical response that can be
observed by a third party. Therefore, patients who are
physically unable to produce such a response, such as
patients who have quadriplegia or neuromuscular disor-
ders or are receiving neuromuscular blocking agents,
cannot be assessed with these tools. Patients with com-
promised hemodynamic status, who account for a large
proportion of critically ill adults, are also at risk; these
patients were often excluded in the aforementioned
studies.
28,30,39
Therefore, the validity of observational pain
scales in patients with hemodynamic instability needs
to be further explored.
Few investigations have addressed the assessment
and treatment of chronic pain in the ICU. Furthermore,
delirium and agitation are common in the ICU; 28% to
87% of ICU patients experience one or both of these con-
ditions at least once during their stay in the unit.
13
The
presence of delirium or agitation makes ascertaining a
pain level difficult. Currently, no pain assessment tools
have been validated in patients who are critically ill or
are being treated with mechanical ventilation who are
concurrently delirious or agitated.
Finally, pain is a complex, personal experience that
cannot easily be adequately described and treated with-
out a patients self-report. Pain management providers
often use describing words such as burning or hot
to indicate specific types of pain (eg, neuropathic pain).
12
Without the benefit of that type of subjective data,
patients may be at risk for receiving a less effective phar-
macological agent (eg, opioids for the treatment of neu-
ropathic pain).
43
Future studies on strategies that promote
self-report of pain in critically ill patients who are sedated
and/or being treated with mechanical ventilation would
contribute much to the advancement of pain assessment.
Conclusion
The rates of uncontrolled pain in critically ill patients
remain unacceptably high. A systematic assessment of
pain should be done routinely, and self-report by the
patient should be the primary basis for pain evaluation
whenever possible. The routine assessment of pain with
an observational pain assessment instrument can decrease
ICU length of stay; decrease the duration of mechanical
ventilation; and increase the satisfaction of patients,
patients family members, and health care providers.
4,25
Of the available observational pain scales, the CPOT has
shown superior reliability and validity when used in
nonverbal critically ill adults. However, the CPOT should
be used cautiously in evaluating patients who have chronic
pain or concurrent delirium. More research is indicated
in the assessment of pain in patients incapable of spon-
taneous neuromuscular movement and in those with
chronic pain. CCN
Financial Disclosures
None reported.
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78 CriticalCareNurse Vol 33, No. 3, JUNE 2013 www.ccnonline.org
CNE Test Test ID C1333: Observational Pain Scales in Critically Ill Adults
Learning objectives: 1. Describe the impact of uncontrolled pain on critically ill patients 2. Identify 2 validated pain scales for critically ill patients
3. Describe instrument reliability and validity when considering pain scales for critically ill patients
Program evaluation
Yes No
Objective 1 was met q q
Objective 2 was met q q
Objective 3 was met q q
Content was relevant to my
nursing practice q q
My expectations were met q q
This method of CNE is effective
for this content q q
The level of difficulty of this test was:
qeasy qmedium qdifficult
To complete this program,
it took me hours/minutes.
1. Which of the following statements best describes the pain response?
a. Inhibition of nociceptors transmits pain impulses to the ventral horn of the spinal cord.
b. Chronic and acute pain pathophysiology is related to direct tissue injury transmitted
by peripheral nerves.
c. After tissue injury, inflammatory mediators stimulate pain impulses to be sent to
the dorsal horn of the spinal cord.
d. The inhibition of the somatosensory cortex results in the pain localization.
2. Which of the following statements describes the Adult Nonverbal Pain Scale
(NVPS)?
a. Both behavioral and physiologic data demonstrate validity of the NVPS.
b. The domains of NVPS include behavioral, physiologic, and autonomic scoring
between 0 and 10.
c. The basis of the NVPS scale is well-studied in adults and children.
d. An NVPS score of 2 in the physiologic category indicates a change in heart rate of
<20 beats/min.
3. Which of the following statements most accurately reflects the issue of pain in
critically ill patients?
a. Sedation of critical care patients prevents the pain response from occurring.
b. Critical illness blunts the pain response in critically ill patients.
c. Studies indicate no reliable scales for pain assessment in critically ill patients.
d. Pain tools for patients who receive mechanical ventilation are advocated by multiple
professional societies.
4. Which of the following statements best describes the interrater reliability of the
NVPS?
a. The revised version of the NVPS retained the 90% interrater reliability.
b. The internal consistency of the NVPS in several studies was fair; however, interrater
reliability remained high.
c. Interrater reliability means that the patient self-reported a similar pain rating as the
one observed.
d. Facial expressions in the NVPS demonstrated the highest score of interrater reliability.
5. Which of the following statements describes the correct usage of the Critical-
Care Pain Observation Tool (CPOT)?
a. Pain observation include facial expression, muscle tension, upper limb movements,
and reaction to endotracheal suctioning.
b. This tool is designed to be used with both intubated and nonintubated critical care
patients.
c. The only observational tool that provides a reliable pain intensity assessment.
d. This tool should be used for patients with delirium only.
6. Which of the following statements most accurately describes the review of pain
scales in the literature?
a. Physiologic data are the most sensitive indicators for pain presence.
b. There is sufficient research for the NPAT pain scale to indicate its usage.
c. There is support for the use of the Behavioral Pain Scale (BPS) and CPOT in
noncommunicative critically ill patients.
d. The BPS and CPOT are useful in establishing pain severity in noncommunicative
critically ill patients.
7. Which of the following accurately describes study findings regarding the BPS
and the CPOT?
a. Multiple studies support the use of the BPS and CPOT due to reliability and
validity of the scales.
b. Patients with impaired neuromuscular response can be adequately assessed
with the BPS and CPOT.
c. There is a strong correlation with observational pain scales and patient self-reports.
d. Sensitivity and specificity for both the BPS and CPOT are reported in study
findings.
8. Which of the following statements correctly reflects ventilator considerations
with observational pain assessment?
a. Tolerance of mechanical ventilation is described with higher numbers on the
observational pain scales.
b. Coughing is not a consideration in scoring an observational pain scale.
c. Asynchrony and frequent alarming is addressed in the CPOT.
d. Tolerance of endotracheal suctioning is the best observation to determine pain.
9. Which of the following statements most accurately describes uncontrolled
pain in critically ill patients?
a. The physiologic response to pain can be adequately controlled with steroids
and sedation.
b. High rates of uncontrolled pain are common in the intensive care unit.
c. Psychosocial effects of uncontrolled pain are rarely observed in critically ill
patients.
d. No methods to appropriately address pain except for patient self-reporting
currently exist.
10. Which of the following is the most reliable tool in nonverbal critically ill
patients?
a. NVPS
b. CPOT
c. BPS
d. PAIN
11. Which of the following statements is true about observational pain assess-
ment tools?
a. They are easily incorporated into practice because minimal education is
needed.
b. They are not reliable in assessing the presence of pain in critically ill patients.
c. They can be used to standardize pain assessment for patients receiving mechanical
ventilation.
d. They are mandated by regulatory agencies.
12. Which of the following statements accurately describes the assessment of
body movements in the CPOT?
a. Absence of movement indicates absence of pain.
b. Fully bending upper extremities and finger flexion indicates a score of 3.
c. Muscle tension must be evaluated by the lower extremities.
d. Restlessness is indicated by movements such as attempting to sit up and pulling
tubes.
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