| Key point: This tool indicates the presence or absence of pain,NOT pain intensity. |
- A total score of 2 points or less is the goal (8 points possible)
- A total score of 3 points or greater indicates pain may be present
- If a pain intervention decreases the CPOT total score by at least 2 points, the intervention may be considered effective
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| Instructions: |
- Observe the patient for one full minute at rest
- To rate muscle tension, raise the arm holding at the elbow and hand, and attempt passive flexion
- Once treated for pain, reassess during peak effect to determine response. Assessment during activities such as turning is useful to determine presence or absence of pain
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| Indicator | Score | Description |
| Facial expression | Relaxed, Neutral | 0 | No muscle tension observed |
| Tense | 1 | Presence of frowning, brow lowering, orbit tightening, and levator contraction or any other change (e.g., opening eyes or tearing during nociceptive procedures) |
| Grimacing | 2 | All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube) |
| Body movements | Absence of movements or normal position | 0 | Does not move at all (does not necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection) |
| Protection | 1 | Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements |
| Restlessness/agitation | 2 | Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed |
Compliance with the ventilator (intubated)
OR | Tolerating ventilator or movement | 0 | Alarms not activated, easy ventilation |
| Coughing but tolerating | 1 | Coughing, alarms may be activated but stop spontaneously |
| Fighting ventilator | 2 | Asynchrony: blocking ventilation, alarms frequently activated |
| Vocalization (nonintubated) | Talking in normal tone or no sound | 0 | Talking in normal tone or no sound |
| Sighing, moaning | 1 | Sighing, moaning |
| Crying out, sobbing | 2 | Crying out, sobbing |
| Muscle tension Evaluation by passive flexion and extension of upper limbs when the patient is at rest or evaluation when the patient is being turned | Relaxed | 0 | No resistance to passive movements |
| Tense, rigid | 1 | Resistance to passive movements |
| Very tense or rigid | 2 | Strong resistance to passive movements, unable to complete them |
| Total | | 8 points possible | |