Facial Expression

Relaxed, neutral — no muscle tension observed+0Tense — frowning, brow lowering, orbit tightening, and levator contraction+1Grimacing — all of the above plus eyes tightly closed+2

Body Movements

Absence of movements (no pain) or normal position+0Protection — slow cautious movements, touching or rubbing the pain site, seeking attention through movements+1Restlessness/agitation — pulling tubes, attempting to sit up, moving limbs/thrashing, non-following commands, striking staff+2

Muscle Tension (Evaluate by passive flexion and extension of upper extremity)

Relaxed — no resistance to passive movements+0Tense, rigid — resistance to passive movements+1Very tense or rigid — strong resistance to passive movements (unable to complete them)+2

Compliance with Ventilator (Intubated) OR Vocalization (Extubated/Non-intubated)

INTUBATED: Tolerating ventilator or movement; OR EXTUBATED: No sounds or talking in normal tone+0INTUBATED: Coughing but tolerating ventilation; OR EXTUBATED: Sighing, moaning+1INTUBATED: Fighting ventilator — alarms frequently activated, agitated; OR EXTUBATED: Crying out, sobbing+2

Critical Care Pain Observation Tool (CPOT)

Critical Care Pain Observation Tool (CPOT)