Patients who can’t self-report pain rely on caregivers to accurately assess pain and intervene appropriately. Nurses have several behavioral pain assessment tools available. However, few studies have actually investigated these tools’ usefulness for pain assessment and management at the bedside.

Accurately assessing pain levels in all critically ill patients is the first step in evaluating patients for the presence of delirium. The Behavioral Pain Scale and the Critical-Care Pain Observation Tool are valid and reliable pain assessment tools that can be used for nonverbal patients with intact motor function. When combined with tools to evaluate sedation, such as the Richmond Agitation Sedation Scale or Sedation Agitation Scale, and tools to assess for the presence of delirium, such as the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist, patients will receive the appropriate intervention.

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