Implementing the critical care pain observation tool using the Iowa model.
Abstract: Utilization of the Iowa Model of evidence-based practice (EBP) helps to facilitate change in nursing care. This was observed when an alteration in pain-rating assessment scales needed to be implemented at St. Joseph's Hospital Health Center in Syracuse, NY. Research showed that the Critical Care Pain Observation Tool (CPOT) was psychometrically sound in assessing pain in the nonverbal (unconscious, unresponsive, and sedated) intensive care unit patient population. Successful implementation of a CPOT pilot program in the surgical intensive care unit at St. Joseph's was undertaken using the Iowa Model of EBP. Application of the Iowa Model provided a systematic framework for changing nursing practice by incorporating critical thinking, clinical inquiry and judgment, multidisciplinary collaboration, and facilitation of learning. As evidenced by implementation of the CPOT, organizational implementation of EBP using the Iowa Model positively impacts change across an entire healthcare continuum through the improvement of patient care processes.
Article Type: Report
Subject: Nursing (Practice)
Evidence-based medicine (Practice)
Nurses (Practice)
Pain (Care and treatment)
Pain (Methods)
Pain (Standards)
Patients (Care and treatment)
Patients (Management)
Author: Kowal, Christopher David
Pub Date: 03/22/2010
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Spring-Summer, 2010 Source Volume: 41 Source Issue: 1
Topic: Event Code: 350 Product standards, safety, & recalls; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: Iowa Geographic Code: 1U4IA Iowa
Accession Number: 242591404
Full Text: Nursing care based on habit or routine is not always founded on best evidence and may not be helpful to the patient or make wise use of hospital capital (Taylor-Piliae, 1999). Protection of these "sacred cows" and "golden geese" of common practice should be questioned by every professional involved in patient care.

Nurses are not only responsible for providing basic care, but they are also charged with impacting the process of care to ensure the best patient outcomes. Nurses should assist in bringing about change to improve outcomes through the use of evidence-based practices (EBP). Utilization of modern technology to standardize the process and method of care along with updating and developing new protocols and infrastructures through research are the best ways to bring about such changes.

Healthcare models and nationally recognized guidelines exist to insure that the latest evidence is integrated into new pathways of care that promote best-practice outcomes for any patient population. Many standardized methods and practice models are available that may be accessed to guide improvements in quality care and outcomes. Such improvements come through changes in process (Ackley, Ladwig, Swan, & Tucker, 2007).

Involvement in these positive changes makes nursing exciting and cutting-edge. Best-practice care methods are becoming the expectation in bringing about positive outcomes for patients and families. Nurses are becoming more informed and responsible about the care they deliver due to new demands being made by patients and families who are increasingly healthcare savvy due to knowledge gained through the media, technology, and the Internet (Curley, 2004).

Evidence-based practice models

Dontje (2007) found that nursing care models stress EBP as the foremost path to changing practice. Nurses need to become the ambassadors of EBP simply because they are the ones to perform the practice. Structuring nursing practice founded on best evidence can be simplified when a method of implementation and infrastructure is followed (University of Iowa Hospitals and Clinics, 2009). There are several different process and mentor models available to nurses that facilitate the execution of EBP. Process models include the Stetler, DiCenso and colleagues, Iowa, and Rosswurm and Larrabee models (Fineout-Overholt, Melnyk, & Schultz, 2005). Examples of mentorship models include the Clinical Scholar and Advancing Research and Clinical Practice Through Close Collaboration models (Fineout-Overholt et al., 2005).

EBP is, in reality, larger than the nursing profession, and it needs to be integrated into the organizational culture as a mainstay for practice change (Titler et al., 2001). All hospital employees need to be made aware of the process of EBP in order to meet the growing demands of educated patients and the rapid changes in practice. Nurses, as cornerstones in the foundation of the healthcare implementation structure, need to help disseminate information in support of the EBP process, because they have first-hand knowledge of its value and worth. The best way to encourage EBP in the workplace is to include it in quality improvement projects. In order to do this, nurses need to become familiar with conducting literature searches, critiquing search findings, and developing methods of practice change based on one of the process or mentor models.

The Iowa model

The Iowa Model of EBP developed by Titler and colleagues (2001) has been found to be one of the most appropriate guides for implementing practice change for nursing at the hospital or organizational level. The model directs change based on current evidence used in practice combined with the viewpoints of the practitioner, the healthcare team, and the organization (Titler et al., 2001; University of Iowa Hospitals and Clinics, 2009). The Iowa Model takes into account the entire healthcare system (patient, provider, and organizational infrastructure) along with current research findings when a practice change is proposed for implementation. Nurses involved in the step-wise use of the Iowa Model engage in situational recognition and outcome development related to putting new evidence into practice (University of Iowa Hospitals and Clinics, 2009).

Steps to implementing the Iowa model

The steps of the Iowa Model (Figure 1) include (a) problem identification, (b) forming a team, (c) a critique of the relevant literature, (d) implementing practice change, and (e) dissemination of findings (Titler et al., 2001). Nursing, guided at times by inter- and multidisciplinary collaboration, determines whether the problem is a priority for the organization and if change would directly improve patient outcomes. The team critiques the available research to identify its supporting levels of evidence and whether it can be used to guide practice change. If research is unavailable, guidelines, expert opinions, case studies, and reports may also be critiqued and used as evidence. New research may also be conducted in order to develop sufficient information to guide change. Finally, the change is piloted and either adopted into practice or the process begins again. If new practice is implemented, the outcomes are monitored, and the results are disseminated (Titler et al., 2001; University of Iowa Hospitals and Clinics, 2009).


PICO question development

Practice changes are best driven by questions of clinical relevance related to the desired alteration. A change adequately supported by research should be implemented if it is appropriate for the patient, staff, and organization (Ciliska, 2005). Learning to ask the right practice question assists the nurse in finding the appropriate information to effect process change. Engberg and Schlenk (2007) found question development to be a requirement for nurses who use EBP. In 1997, Sacketts and colleagues (Engberg & Schlenk, 2007) identified four components to forming an appropriate clinical practice question: patient, intervention, comparison, and outcome (PICO). Once the PICO question has been formed, a literature search is performed. Successful search and critique of the literature is a critical component for nurses to master when implementing change driven by EBP (Klem & Weiss, 2005). According to Fineout-Overholt and colleagues (2005), correct literature appraisal assists how the evidence will be used to answer the PICO question or implement a practice change. Even less-than-perfect studies can have value as examples for EBP change, and nurses should not try to eliminate studies by pointing out their flaws. They should note whether or not studies can be at all beneficial to practice change despite their flaws.

Adopting change ... or not

Following a thorough critique of the literature, a decision is made whether or not a solid research base exists to guide change. If so, a direct conversion or pilot implementation of best evidence occurs. If there is insufficient research or other literature available to guide change, then new research can be done to help guide a change (St. Francis Medical Center, 2006).

Implementing the model: A case study

While undertaking the rigorous process of applying for the American Association of Critical Care Nurses Beacon Award for Critical Care Excellence, staff of the surgical intensive care unit (SICU) governance committee at St. Joseph's Hospital Health Center in Syracuse, NY discovered a problem trigger: The unit did not have an accurate assessment tool to rate pain in the nonverbal (unconscious, unresponsive, or sedated) patient population which was a high-volume group in the SICU. The rating tool being used was the Pain Assessment in Advanced Dementia (PAINAD) scale (Figure 2; Warden, Hurley, & Volicer, 2003). At the time of implementation at St. Joseph's, the PAINAD scale was the most behaviorally appropriate pain assessment tool available, but it was not population-specific.

Without a proper tool to assess pain in the nonverbal patient population, it is difficult to achieve timely, appropriate, and patient-specific interventions that improve quality of care. It is even more difficult, if not impossible, to assess a patient's stability, complexity, predictability, and resiliency if their pain is not being properly assessed and addressed through appropriate interventions. The patient becomes more vulnerable to the actual stressor of pain, which will adversely affect their outcome (Markey, 2001).

Staff recognized a high potential for inappropriate assessment of patients' pain when using the wrong tool, which could lead to under-treated pain levels and adverse outcomes (Herr et al., 2004). The hospital's pain committee acknowledged the SICU nursing staff's concerns that perhaps there was another pain scale that had been recently developed which would be better suited for patient needs. The unit's governance committee (UGC) was eager to meet the challenges of investigating and implementing change in practice. Staff was interested to discover if using a population-specific pain rating scale could not only improve patients' comfort levels but potentially impact other outcomes such as length of stay or intubation.

The ICU clinical nurse specialist guided the UGC toward the concept of EBP and how it can positively impact change in nursing process. The UGC acted as the task force team for this project, and they were shown how to implement a proposed practice change through utilization of the Iowa Model. St. Joseph's adopted the model to implement EBP change because it was found to be the most specific guide for practice change at both the unit and institutional levels (Ackley et al., 2007; University of Iowa Hospitals and Clinics, 2009).

A PICO question was developed by the UGC taskforce: Is pain documentation in the nonverbal adult ICU patient better quantified using the current (PAINAD) scale versus another tool that could potentially be more behaviorally objective? First, a search for the most current literature relative to the combination of keywords and phrases, "pain assessment," "critically ill," and "behavioral pain scales" was conducted using CINAHL, Mosby's Nursing Consult, Cochrane, PubMed, and Medline databases. The search yielded articles on several pain-rating tools available for nonverbal patients. The UGC narrowed their decision down to two potential pain scales: the Critical Care Pain Observation Tool (CPOT) (Figure 3) (Gelinas, Fillion, & Puntillo, 2009) and the Behavioral Pain Scale (BPS) (Gelinas, Fillion, Puntillo, Viens, & Fortier, 2006; Payen et al., 2001), because both scales assessed pain in the typical ICU patient population: nonverbal, unresponsive, sedated, and intubated patients. A more specific database search for the phrases, "Critical Care Pain Observation Tool" and "Behavioral Pain Scale" was also conducted. Database results were limited for the CPOT, so a broad Internet search was also performed looking for relevant information.

A summary of literature findings, including the UGC's recommendations for change, was presented to the St. Joseph's pain committee. The summary presented several exemplar studies of tools that were shown to be reliable and valid (Gelinas, Loiselle, LeMay, Ranger, Bouchard, & McCormack, 2008) for the justification and utilization of either the BPS (Payen et al., 2001) or the CPOT (Gelinas & Johnston, 2007; Gelinas, 2009). The UGC felt the CPOT was more appropriate to implement because the BPS, while similar, did not take ventilation into account (Payen et al., 2001). The CPOT assessed nonverbal patient indicators of pain in four pertinent areas: facial expression, body movements, muscle tension, and ventilator compliance for intubated patients or vocalization for extubated patients or patients who were never intubated but nonverbal (Gelinas & Johnston, 2007).

Following the Iowa Model algorithm, the UGC decided that the evidence warranted a change in practice. A proposal was developed and presented to the pain committee to implement a CPOT pilot program. Pain committee members expressed hesitation to trialing the pilot because the CPOT used a different numeric rating scale. A maximum score of 8 was allowed by the CPOT (Gelinas, Fillion, Puntillo, Viens, et al., 2006). Both the PAINAD scale (Horgas & Miller, 2008; Warden, Hurley, & Volicer, 2003) and the Numeric Rating Scale (NRS) (Dunwoody, Krenzischek, Pasero, Polomano, & Rathmell, 2008; Pasero, 2002; Joint Commission, 2009), which are used at St. Joseph's, have maximum scores of 10. When using these current scales (PAINAD/NRS), comfort interventions were administered to a patient if they rated their pain "moderate to severe," or greater than or equal to 4 on a scale of 10 (Dunwoody et al., 2008). The pain committee's concern was that the CPOT rating would be confusing with its more narrow scale.

It is noteworthy to indicate here that nursing education is now focusing on interventions to improve patients' comfort no matter what their numeric rating (Pasero, 2009). Any patient assessed to be in discomfort should be provided with an intervention in order to achieve an improved level of comfort. This evidence was used to strengthen the case for implementing the CPOT.

According to the CPOT scale guidelines (Gelinas & Johnston, 2007; Gelinas, 2009) it was appropriate to provide nursing intervention for a pain score greater than or equal to 2. This rationale paralleled the current St. Joseph's policy for pain intervention to occur at assessed "moderate" or "severe" levels (greater than or equal to 4 out of 10 by the NRS and PAINAD scale) as recommended by the Joint Commission (2009). This part of the process was daunting and, at times, frustrating because it took approximately 9 months from the time of initial proposal to being granted permission by the pain committee to pilot the CPOT.

The next phase of infrastructure focused on staff awareness, education, and buy-in for all clinical staff and allied health professionals. This implied step is not directly listed in the Iowa Model algorithm. However, acquiring buy-in through consensus is important towards increasing the desire to implement practice changes (Rolls & Elliot, 2008). A cross section of surgeons, physicians, anesthesiologists, and nurse practitioners, as well as all staff nurses in the SICU, were made aware of the proposal for a practice change. They were educated on CPOT use, and the pilot proposal was well accepted.

Discussions with staff also generated more questions directed toward the ventilated patient population. If the CPOT was shown to work in the SICU population, and comfort levels were improved in post-operatively intubated patients, would patients get extubated sooner? If so, would ventilator-associated pneumonia (VAP) rates be affected? Would extubated patients continue to verbalize comfort? As a result of these discussions, the UGC decided to include monitoring of average duration of intubation (DOI) times as well as VAP rates throughout the pilot.

Inservice education was conducted with nursing staff on how to utilize the CPOT to assess pain before and after interventional comfort measures were carried out. Information technology staff created an online assessment tool to allow CPOT documentation in St. | Joseph's Care Manager, the nursing department's computerized documentation system.

The CPOT pilot program was implemented and monitored in the SICU from January to May of 2009. Achievable outcomes selected for monitoring included the patient's initial pain assessment rating, type of pain relief implemented, and postintervention rating. Timeliness of postintervention pain reassessment was monitored to evaluate staff compliance with St. Joseph's policy that requires reassessment to take place within 2 hours of intervention (St. Joseph's Hospital Health Center, 2008, June). DOI was also monitored in postoperatively ventilated patients to evaluate if comfort levels affected ventilator times.

Written CPOT guidelines were attached to each SICU bedside computer for all staff to reference. St. Joseph's SICU was the first unit within its network to pilot use of the CPOT. Long-range plans were made to utilize the CPOT for nonverbal patients in the hospital's medical intensive care unit, postanesthesia care unit, emergency department, one-day surgery unit, and endoscopy unit.

Data review

A retrospective electronic chart review was performed on 104 SICU patients for the month of May 2009. The CPOT was used a total of 1,603 times, producing more than 1 6,000 pieces of data. All nonverbal patients in the pilot were mechanically ventilated due to surgical intervention or from respiratory failure. Of these, 52% were postsurgical patients extubated within 12 hours of surgery. Each had preextubation CPOT scores less than or equal to 2.

In one example from this group of patients, retrospective data were reviewed from the chart of a long-term, nonverbal, developmentally delayed, ventilator-dependent patient. CPOT documentation was recorded 202 times for the month of May, showing that staff members were compliant with following hospital policy for assessing comfort/pain in the adult critical care patient at least every 4 hours (St. Joseph's Hospital Health Center, 2008, November). In 13% of these occurrences the patient's pain score was greater than or equal to 2, and after comfort interventions were implemented, 87% of the reassessments resulted in a reduced pain score. On three separate occurrences, staff intervention was not documented when a pain score indicated the need for it, and reeducation was performed for these individuals.

Four CPOT point-prevalence monitors were performed in the SICU on a similar patient population during June 2009. Retrospective electronic chart reviews were again performed to track patients' initial pain assessment rating, type of pain relief implemented, postintervention rating, timeliness of pain reassessment, and duration of intubation (if applicable). Out of 41 patients evaluated, 34% required comfort measures for scoring pain greater than or equal to 2. Documented staff compliance for implementing comfort interventions for these patients measured 100%. Postintervention assessments showed 93% of the patients receiving an intervention scored less than or equal to their original rating. It was also noted that in the postextubation group, 40% of the patients' subjective NRS scores were rated less than or equal to their equivalent preextubation, objective CPOT scores. This showed staff that adequate pain control was achievable using the CPOT. As a point of interest, it should also be noted here that 2 of the 41 patients were "appropriately" evaluated using the PAINAD scale: One patient was found to have spoken incoherently and the other had a history of chronic changes in level of consciousness similar to dementia.

Case study conclusions

The UGC and SICU management felt strongly that the evidence overwhelmingly concluded the following: As a result of utilizing a more precise pain-rating tool targeting the current St. Joseph's adult critical care patient population, better comfort management and improved patient outcomes occurred. More ventilated, postsurgical patients expressed less discomfort, and, when compared to last year's rates, postsurgical DOI times decreased by several hours. Management also concluded that improved comfort allowed for increased compliance with ventilator weaning, which, it was hypothesized, also contributed to shorter intubation times. Also, recently extubated patients expressed greater comfort (according to NRS scoring) when participating with early inspiratory exercises. Contributing to these improved outcomes, the SICU has had only one case of VAP since January 2009. Prior to then, VAP rates averaged about 1 per month. In conclusion, the UGC recommended that St. Joseph's adopt the use of the CPOT in the SICU and other applicable areas of the hospital. In September of 2009, the hospital pain committee approved the use of the CPOT.

Future directions

As a result of original pilot study outcomes, new evidence, or trends from original process and outcome data, modifications or adaptations of a pilot program may be made to have a more lasting effect on a larger clientele base (Titler et al., 2001; University of Iowa Hospitals and Clinics, 2009). For example, future innovations to the current CPOT measurement parameters may allow this new tool to be used on a broader class and population of patients, such as nonverbal patients outside of critical care or tracheostomy patients on medical-surgical units. Staff members outside of critical care have already verbalized this desire, therefore it will be a focus for the future.

Adopting EBp

In order to gain acceptance of a new healthcare change, staff need to be made aware of the available evidence and educated about its value to practice. For example, a literature review convinced direct care and management staff at St. Joseph's that use of the CPOT could improve the quality and outcomes of patient care. This, along with education to facilitate understanding, helped to increase the value of using new evidence in practice. The journey eventually assisted in the implementation of the proposed pilot.

EBP needs to be taught to all hospital employees in order to gain institutional buy-in and compliance to its concepts and methods of application within the practice environment. Strategies to maintain consistent, reproducible employment of EBP in patient populations and practice areas throughout the network require utilization of standardized EBP implementation tools such as the Iowa Model.

Promoting a knowledge-sharing culture

Nurses need to promote best-practice outcomes, as they are the experts who recognize, through experience, education, and clinical judgment, when a practice is inappropriate, outdated, or targeting the wrong patient population. Nurses need to apply critical thinking through clinical inquiry in order to discover if there is new or better evidence available to improve care. The art of caring practice includes promoting quality care and best-practice outcomes while simultaneously facilitating learning (Markey, 2001).

EBP is a vital and necessary component for providing superior healthcare, and it is an important constituent of quality nursing practice. The Iowa Model of EBP offers nurses a scaffold with which to build an infrastructure of change within their workplace. Such a specific guideline for structuring change supplies nurses with a method to develop and answer practice questions through research utilization and application of current recommendations to practice. The professional nurse must champion the development of EBP in their workplace while proactively and progressively enacting it in the quality of care provided to patients (Dontje, 2007).

Nurses should take up the relentless quest to advocate for EBP improvements by engaging in frequent assessment, evaluation, and questioning of current methods of care. Healthcare practices can be guided by research-based evidence as well as practical wisdom from the present culture (Markey, 2001). Proper knowledge management, including the development, sharing, and transfer of personal and public facts, data, and information, along with utilization of EBP, will promote the best quality outcomes for patients (Markey, 2001).

The profession of nursing is constantly changing. Every day, new practice guidelines and evaluation tools are being developed and presented based on research and innovation. Nurses should grasp this opportunity to create new infrastructures of care administration, competency, and practice that are patient-specific (Curley, 2004).

Let the evidence speak for itself. Research and implementation of EBP must drive process improvement that facilitates best-practice outcomes for patients, families, and nurses. Utilization of the Iowa Model to structure EBP change, such as the implementation of the CPOT in St. Joseph's SICU, ensures that a careful, step-wise method of process transformation is followed at all times. Best practice, based on evidence, ensures that the heart of nursing is always protected and cared for: The heart of nursing is the patient.

CE Activity Alert:

Put your reading to work! Turn to page 17 for a 1.1-hour CE activity related to this article.

CE Activity: Implementing the Critical Care pain Observation Tool using the Iowa Model

Thank you for your participation in "Implementing the Critical Care Pain Observation Tool Using the Iowa Model," a new l. l -hour CE activity (CE activity code: 87THY5) offered by NYSNA to RNs and LPNs. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.


In order to receive contact hours for this educational activity, participants must:

* Read the article on page 4 of this issue of Journal.

* Successfully complete the posttest with a minimum score of 80%. Participants have two attempts to successfully complete the posttest.

* Complete an evaluation.

* Mark your posttest answers and evaluation responses on the answer sheet provided on page 19.

The participant will also need to pay a fee of $5 for NYSNA members and $10 for nonmembers. Participants can pay by check (made out to NYSNA; please include "Journal CE" on your check) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA. See the answer sheet for more information.


The goal of this educational activity is to demonstrate that the utilization of the Iowa Model of evidence-based practice helps to facilitate change in nursing care.


1. Describe the steps involved in implementing the Iowa Model of evidence-based practice

2. Identify the four assessment indicators of the Critical Care Pain Observation Tool

3. Identify the impact evidence-based practice has upon quality nursing care

The New York State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

NYSNA has nothing to declare related to this educational activity. NYSNA wishes to disclose that no commercial support was received for this educational activity.

The author is the recipient of the Philips Medical System grant for nursing research through the AACN (critical care) for 20/0.

All other planners/presenters involved with the development of this independent study have declared that they have no vested interest.

Implementing the Critical Care pain Observation Tool using the Iowa model

Please answer the questions below using the answer sheet on page 19. Complete the answer sheet by putting the letter of your answer next to the corresponding question number. Each question has only one correct answer. A score of 80% is needed to successfully pass this posttest.

The 1.1 contact hours for this program will be offered until August 31,2013.

1. Nursing care should be based upon:

(a) Word of mouth

(b) The best available evidence

(c) Tradition

(d) Unit standards

2. Examples of evidence-based practice process models include:

(a) The Stetler Model

(b) The DiCenso & Colleagues Model

(c) The Iowa Model

(d) The Rosswurm & Larrabee Model

(e) All of the above

3. The Iowa Model of evidence-based practice directs change:

(a) Based upon the current evidence used in practice combined with the viewpoints of the practitioner, the healthcare team, and the organization

(b) According to the available evidence already being used in practice

(c) According to the latest research performed in the field in question

(d) Based upon how care has been delivered by the most staff in the facility

4. The Critical Care Pain Observation Tool:

(a) Is used to assess all types of intensive care unit patients

(b) Can be used to assess non-critical care patients

(c) Assesses nonverbal and verbal patient indicators to pain

(d) Assesses indicators to pain in the areas of: facial expression, vital sign fluctuations, body movement, and muscle tension

5. Pilot study outcomes can:

(a) Stimulate the innovation of new practice questions

(b) Lead to the development of future research studies

(c) Guide changes in current practice

(d) All of the above



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Rolls, K. D., & Elliot, D. (2008). Using consensus methods to develop clinical practice guidelines for intensive care: The intensive care collaborative project. Australian Critical Care, 21(4), 200-215. doi:10.1016/j.aucc.2008.08.003.

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Warden, V, Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical Director's Association, 4(1), 9-l5.

Christopher David Kowal, BS, MSN-MOL-Ed, RN, CCRN-CMC-CSC

Christopher David Kowal is a staff nurse in the surgical intensive care unit at St. Joseph's Hospital Health Center in Syracuse, NY, and a research fellow for the Foundation of New York State Nurses
Figure 2. The Pain Assessment in Advanced Dementia Scale rates pain
on a scale of 0 to 10; "moderate to severe" pain is indicated by a
score greater than or equal to 4 (Warden, Hurley, & Volicer, 2003).

Pain Assessment in Advanced
Dementia Scale

Items *               0                 1                   2

Breathing        Normal         Occasional          Noisy, labored
independent                     labored             breathing. Long
of                              breathing.          period of
vocalization                    Short period of     hyperventilation.
                                hyperventilation.   Cheyne-Stokes

Negative         None           Occasional          Repeated
vocalization                    moan or groan.      troubled calling
                                Low-level           out. Loud
                                speech with         moaning or
                                a negative or       groaning. Crying.

Facial           Smiling or     Sad.                Facial
expression       inexpressive   Frightened.         grimacing.

Body             Relaxed        Tense.              Rigid. Fists
language                        Distressed          clenched. Knees
                                pacing.             pulled up. Pulling
                                Fidgeting.          or pushing away.
                                                    Striking out.

Consolability    No need to     Distracted or       Unable to
                 console        reassured by        console,
                                voice or touch.     distract, or
                                                    Total **

Items *          Score






* Five-item observational tool.

** Total scores range from 0 to 10 (based on a scale of 0 to 2
for five items), with a higher score indicating more severe pain
(0 = "no pain" to 10 = "severe pain").

Figure 3. The Critical Care Pain Observation Tool can assess
nonverbal patient indicators of pain in four areas: facial
expression, body movements, muscle tension, and ventilator
compliance (Gelinas et al., 2008).

The Critical Care pain Observation Tool

Indicator              Description            Score

Facial expression      No muscular tension    Relaxed, neutral    0

                       Presence of            Tense               1
                       frowning, brow
                       lowering, orbit
                       tightening, and
                       levator contraction

                       All of the above       Grimacing           2
                       facial movements
                       plus eyelid tightly

Body movements         Does not move at all   Absence of          0
                       (does not              movements
                       necessarily mean
                       absence of pain)

                       Slow, cautious
                       movements, touching    Protection          1
                       or rubbing the pain
                       site, seeking
                       attention through

                       Pulling tube,
                       attempting to sit      Restlessness        2
                       up, moving limbs/
                       thrashing, not
                       following commands,
                       striking at staff,
                       trying to climb out
                       of bed

Muscle tension         No resistance to       Relaxed             0
                       passive movements

Evaluation by          Resistance to          Tense, rigid
passive flexion and    passive movements      Very tense or       2
extension of upper     Strong resistance to   rigid
extremities            passive movements,
                       inability to
                       complete them

Compliance with the    Alarms not             Tolerating          0
ventilator             activated, easy        ventilator or
(intubated patients)   ventilation            movement

OR                     Alarms stop            Coughing but        1
                       spontaneously          tolerating          2
                       Asynchrony: blocking   Fighting
                       ventilation, alarms    ventilator
                       frequently activated

Vocalization           Talking in normal      Talking in normal
(extubated patients)   tone or no sound       tone or no sound    0

                       Sighing, moaning       Sighing, moaning
                       Crying out, sobbing    Crying out,         2
Total, range                                  sobbing             0-8
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