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Critical-Pain Observation Tool (CPOT)

Critical-Pain Observation Tool (CPOT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

The Critical-Care Pain Observation Tool (CPOT)
(Gélinas et al., AJCC 2006; 15(4):420-427)

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 0
or normal position
Does not move at all (doesn’t 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 patients)

Tolerating ventilator or
movement 0

Alarms not activated, easy ventilation

Coughing but tolerating 1 Coughing, alarms may be activated but stop

Fighting ventilator 2 Asynchrony: blocking ventilation, alarms
frequently activated
Vocalization (extubated patients)

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 Relaxed 0 No resistance to passive movements
Evaluation by passive flexion and
extension of upper limbs when patient
is at rest or evaluation when patient is
being turned
Tense, rigid 1 Resistance to passive movements

Very tense or rigid 2 Strong resistance to passive movements or
incapacity to complete them

TOTAL ___ / 8
Free teaching CPOT video available at:
Funded and created by Kaiser Permanente Northern California Nursing Research (KPNCNR)
Caroline Arbour, RN, B.Sc., PhD(c)
Ingram School of Nursing,
McGill University

Brief description of each CPOT behavior:

Facial expression: The facial expression is one of the best behavioral indicators for pain
assessment. A score of 0 is given when there is no muscle tension observable in the patient’s
face. A score of 1 consists of a tense face which is usually exhibited as frowning or brow
lowering. A score of 2 refers to grimacing, which is a contraction of the full face including eyes
tightly closed and contraction of the cheek muscles. On occasion, the patient may open his or
her mouth, or if intubated, may bite the endotracheal tube. Any other change in facial
expression should be described in the chart, and given a score of 1 if different from a relaxed
(0) or grimacing (2) face.

Body movements: A score of 0 is given when a patient is not moving at all or remains in a
normal position as per the nurse’s clinical judgment. A score of 1 refers to protective
movements, meaning that the patient performs slow and cautious movements, tries to reach
or touch the pain site. A score of 2 is given when the patient is restless or agitated. In this
case, the patient exhibits repetitive movements, tries to pull on tubes, tries to sit up in bed, or
is not collaborative. Of note, body movements are the less specific behaviors in relation with
pain, but are still important in the whole evaluation of the patient’s pain.

Compliance with the ventilator: Compliance with the ventilator is used when the patient is
mechanically ventilated. A score of 0 refers to easy ventilation. The patient is not coughing
nor activating the alarms. A score of 1 means that the patient may be coughing or activating
the alarms but this stops spontaneously without the nurse having to intervene. A score of 2 is
given when the patient is fighting the ventilator. In this case, the patient may be coughing and
activating the alarms, and an asynchrony may be observed. The nurse has to intervene by
talking to the patient for reassurance or by administering medication to calm the patient down.
It is important that the nurse auscultates the patient to check for the position of the
endotracheal tube and the presence of secretions as these factors may influence this item
without being indicative of pain.

Vocalization: Vocalization is used in non-intubated patients able to vocalize. A score of 0
refers to the absence of sound or to the patient talking in a normal tone. A score of 1 is given
when the patient is sighing or moaning, and a score of 2 when the patient is crying out (Aïe!
Ouch!) or sobbing.

Muscle tension: Muscle tension is also a very good indicator of pain, and is considered the
second best one in the CPOT. When the patient is at rest, it is evaluated by performing a
passive flexion and extension of the patient’s arm. During turning, the nurse can easily feel
the patient’s resistance when she is participating in the procedure. A score of 0 is given when
no resistance is felt during the passive movements or the turning procedure. A score of 1
refers to resistance during movements or turning. In other words, the patient is tense or rigid.
A score of 2 consists of strong resistance. In such cases, the nurse may be unable to
complete passive movements or the patient will resist against the movement during turning.
The patient may also clench his/her fists.

Directives of use of the CPOT

1. The patient must be observed at rest for one minute to obtain a baseline value of
the CPOT.
2. Then, the patient should be observed during nociceptive procedures (e.g.
turning, wound care) to detect any changes in the patient’s behaviors to pain.
3. The patient should be evaluated before and at the peak effect of an analgesic
agent to assess whether the treatment was effective or not in relieving pain.
4. For the rating of the CPOT, the patient should be attributed the highest score
observed during the observation period.
5. The patient should be attributed a score for each behavior included in the
CPOT and muscle tension should be evaluated last, especially when the
patient is at rest because the stimulation of touch alone (when performing
passive flexion and extension of the arm) may lead to behavioral reactions.

Free teaching CPOT video available at:
Funded and created by Kaiser Permanente Northern California Nursing Research (KPNCNR)

Observation of patient at rest (baseline).

The nurse looks at the patient’s face and body to note any visible reactions for an observation
period of one minute. She gives a score for all items except for muscle tension. At the end of
the one-minute period, the nurse holds the patient’s arm in both hands – one at the elbow,
and uses the other one to hold the patient’s hand. Then, she performs a passive flexion and
extension of the upper limb, and feels any resistance the patient may exhibit. If the
movements are performed easily, the patient is found to be relaxed with no resistance (score
0). If the movements can still be performed but with more strength, then it is concluded that
the patient is showing resistance to movements (score 1). Finally, if the nurse cannot
complete the movements, strong resistance is felt (score 2). This can be observed in patients
who are spastic.

Observation of patient during turning.

Even during the turning procedure, the nurse can still assess the patient’s pain. While she is
turning the patient on one side, she looks at the patient’s face to note any reactions such as
frowning or grimacing. These reactions may be brief or can last longer. The nurse also looks
out for body movements. For instance, she looks for protective movements like the patient
trying to reach or touching the pain site (e.g. surgical incision, injury site). In the mechanically
ventilated patient, she pays attention to alarms and if they stop spontaneously or require that
she intervenes (e.g. reassurance, administering medication). According to muscle tension, the
nurse can feel if the patient is resisting to the movement or not. A score 2 is given when the
patient is resisting against the movement and attempts to get on his/her back.

Facial expressions

* A score of 1 may be attributed when a change in the patient’s facial expression is observed compared with rest assessment (e.g. open eyes,

Inspired by : Prkachin, K. M. (1992). The consistency of facial expressions of pain : a comparison across modalities. Pain, 51, 297-306.
Relaxed, neutral
(no muscle tension)

(frowning, brow lowering, orbit
tightening, little levator contraction)

(contraction of the whole face: frowning,
brow lowering, eyes tightly closed, levator
contraction – mouth may be opened or the
patient may be biting the endotracheal tube)

By Caroline Arbour, RN, B.Sc., PhD(c), Ingram School of Nursing, McGill University


Arbour, C., & Gélinas, C. (2011). Ask the Experts. Setting Goals for Pain Management When
Using a Behavioral Scale: Example With the Critical-Care Pain Observation Tool. Critical Care Nurse, 31, 66-68.

Arbour, C., Gélinas, C., & Michaud, C. (2011). Impact of the implementation of the CPOT on pain
management and clinical outcomes in ventilated trauma ICU patients: A pilot study. Journal of Trauma
Nursing, 18(1), 52-60.

Gélinas, C., Arbour, C., Michaud, C., Vaillant, F., & Desjardins, S. (2011). The 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. International Journal of Nursing Studies, 48(12), 1495-1504.

Gélinas, C. (2010). Nurses’ Evaluations of the Feasibility and the Clinical Utility of the Critical-Care Pain Observation
Tool. Pain Management Nursing, 11(2), 115-125.

Gélinas, C., & Arbour, C. (2009). Behavioral and physiological indicators during a nociceptive procedure in conscious
and unconscious mechanically ventilated adults: Similar or different? Journal of Critical Care, 24, 628.e7-e17.

Gélinas, C., Fillion, L., & Puntillo, K. A. (2009). Item selection and Content validity of the Critical-Care Pain Observation
Tool: An instrument to assess pain in critically ill nonverbal adults. Journal of Advanced Nursing, 65(1), 203-216.

Gélinas, C., Harel, F., Fillion, L., Puntillo, K. A., & Johnston, C. (2009). Sensitivity and specificity of the Critical-Care
Pain Observation Tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain & Symptom
Management, 37(1), 58-67.

Gélinas, C., & Johnston, C. (2007). Pain assessment in the critically ill ventilated adult: Validation of the Critical-Care
Pain Observation Tool and physiologic indicators. The Clinical Journal of Pain, 23 (6), 497-505.

Gelinas, C., Fillion, L, Puntillo, K., Viens, C., & Fortier, M. (2006). Validation of the Critical-Care Pain Observation Tool
in adult patients. American Journal of Critical Care, 15 (4), 420-427.

Gélinas, C., Fortier, M., Viens, C., Fillion, L., & Puntillo, K. (2004). Pain assessment and management in critically-ill
intubated patients: a retrospective study. American Journal of Critical Care, 13 (2), 126-135.

Gélinas, C., Tousignant-Laflamme, Y., Robitaille, A., & Bourgault, P. (2011). Exploring the validity of the
Bispectral Index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated
and mechanically ventilated critically ill adults: A pilot study. Intensive & Critical Care Nursing, 27(1), 46-52.

Tousignant-Laflamme, Y., Bourgault, P., Gélinas, C., & Marchand, S. (2010). Assessing pain behaviors in healthy
subjects using the Critical-Care Pain Observation Tool (CPOT) : A pilot study. The Journal of Pain, 11(10), 983-987.

Author Contact Information

Céline Gélinas, N, PhD
Assistant Professor Researcher
McGill University Centre for Nursing Research and
Ingram School of Nursing Lady Davis Institute
3506, University Street Jewish General Hospital
Wilson Hall, Room 420 3755 Cote Sainte Catherine Road
Montreal, Qc H3A 2A7 Canada Pavilion H, Room H-301.2
Phone: (514) 398-6157 Montreal, Qc H3T 1E2 Canada
Fax: (514) 398-8455 Phone: (514) 340-8222 ext.4645
Email: celine.gelinas@mcgill.ca Fax : (514) 340-7592