Many critically ill adult patients experience significant pain. Because pain is multidimensional and subjective, the patient’s self-report is the gold standard for assessment. However, many adult patients in the intensive care unit cannot self-report pain as a result of an altered level of consciousness, mechanical ventilation, and/or the administration of sedative agents. The lack of self-reporting makes assessing pain in critically ill patients a challenge for nurses, who should consider use of alternatives such as behavioral pain assessment tools.
Assess and document pain for all critically ill adult patients using appropriate and validated tools. For critically ill adults who are unable to self-report pain, use a validated behavioral pain scale, such as the Behavioral Pain Scale in intubated and nonintubated patients or the Critical-Care Pain Observation Tool.
Avoid referring primarily to vital signs for pain assessment of critically ill adult patients.