Table 2.

Pain Assessment Tools for Nonverbal Patients

Assessment Tool	Features	Score Range	Advantages and Disadvantages40
Behavioral Pain Rating Scale 35	4 behavioral domains (restlessness, tense muscles, frowning or grimacing, patient sounds)	Each domain rated on a 3-point scale Total score ranges from 0 (no pain) to 12 (most pain).	Demonstrated reliability and validity only in Post-Anesthesia Care Unit patients without neurological problems or major complications, limiting generalizability to other populations Not tested in ICU, non-ICU settings, or in CCI Accuracy may be decreased if movement is restricted due to sedation, weakness, or restraints Requires some vocal ability 0-12 scoring may be difficult to understand, as many other tools use 0-10 scoring
PAIN Algorithm36	6 behavioral domains (facial expression, movement, posture, vocal sounds, pallor, perspiration) and 3 physiologic indicators (heart rate, blood pressure, respiration) Nurse rates presence or absence of pain behavior in each domain or indicator	Nurse appraisals of pain behaviors converted to 0-10 numeric rating scale Score used to guide management of pain based on algorithm	Moderate reliability and validity found in one study Not tested in non-ICU settings or in CCI Length of the tool may limit clinical utility Pain behavior ratings are not standardized or defined, introducing nurse subjectivity
Behavioral Pain Scale 37	3 behavioral domains (facial expression, upper limb movement, ventilator compliance) 4 items in each domain	Each domain rated on 4-point scale Total score ranges from 3 (no pain) to 12 (most pain)	Acceptable reliability and validity for use with nonspeaking ICU patients Not tested in non-ICU settings or in CCI Inter-rater reliability questionable Accuracy may be low if movement is restricted due to sedation, weakness, or restraints 3-12 score range may be difficult to understand, as many other tools use 0-10 scoring
Nonverbal Pain Scale 38	3 behavioral domains (facial expression, body movement, guarding) and 4 physiologic domains (change in vital signs, change in skin color or temperature, and pupil dilation)	Each domain rated on a 3-point scale (0-2) Total score ranges from 0 (no pain) to 10 (most pain)	Acceptable reliability demonstrated in 1 study in an ICU Construct validity questionable due to inclusion of indicators such as smiling or lying in a normal position, which may not indicate presence or absence of pain Not tested in non-ICU settings or in CCI No rationale provided for vital sign change parameters designated as pain indicator
Pain Behavior Assessment Tool 17	3 behavioral domains (facial expressions, body movements, verbal responses) Varying numbers of descriptors in each domain	Nurse marks presence of any observable descriptor in each domain Instrument is not scored; clinical management of pain based on nursing judgment after noting presence of pain behaviors	Moderate validity demonstrated in a large sample of hospitalized adult medical, surgical, and trauma patients in both general inpatient and ICU settings Reliability not reported Not tested in CCI Simple for bedside nurses to use Provides operational definitions to standardize behavioral observations Pain management relies on nursing judgment due to lack of summed score to indicate increased pain severity
Critical Care Pain Observation Tool 39	4 behavioral domains (facial expression, movements, muscle tension, ventilator compliance)	Each domain rated on a 3-point scale (0-2) Total score ranges from 0 (no pain) to 8 (most pain)	Validity is questionable due to instrument's inability to differentiate between patients reporting pain and those not reporting pain Inter-rater reliability high except in verbal patients; no instrument reliability data reported Not tested in CCI