Assess, Prevent, and Manage Pain

The A component of the ABCDEF Bundle refers to assessing, preventing and managing pain.

Pain is an unpleasant sensory and emotional experience. It is best reported by the person who is experiencing it, although self-reporting can be a challenge in the ICU. However, the inability to communicate verbally does not negate the possibility that a patient is experiencing pain.

The ABCDEF Bundle makes the following recommendations for assessment, treatment and preventions.


Implementation Tools
Implementing the A component of the ABCDEF bundle
  • Compare valid and reliable pain assessment tools.
  • Identify special challenges to effective pain assessment, prevention, and management.
  • Integrate effective strategies to prevent and manage pain into everyday clinical practice.
  • Incorporate evidence from the Pain, Agitation, and Delirium (PAD) Guidelines, including Quality of Evidence and Strength of Recommendations.



We know that pain affects the majority of ICU patients. Patients with diminished communication or cognitive capabilities are at risk of experiencing higher levels of pain. Reliable and valid pain assessment is the foundation for effective pain treatment, although choosing the best intervention to treat pain is challenging.

The ICU Liberation’s implementation tools offer a stepwise approach to pain assessment, suggesting assessment in this order:
  • Attempt to obtain the patient’s self-report of pain.
  • Look for behavioral changes.
  • Ask the family to help identify pain behaviors.
  • Assume that pain is present.

Tools for Pain Assessment

Numerical Rating Scale (NRS)

Behavioral Pain Scale (BPS)

Behavioral Pain Scale Training Poster

Critical-Care Pain Observation Tool (CPOT)

Critical-Care Pain Observation Tool: How to Use it in Your ICU (video)



ICU Liberation recommends that, for treating pain:
  • IV opioids should be considered as the first-line drug class of choice for non-neuropathic pain.
  • All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective.

Pharmacologic Treatment
Nonpharmacologic Interventions



The most important step for clinicians seeking to prevent pain is to recognize the painfulness of common ICU procedures. Turning, wound drain removal, wound care, chest tube removal and arterial line insertion are rated among the most painful procedures. Administer pre-procedural analgesia and/or nonpharmacologic interventions and consider the same for other procedures. Treat pain first!


 Additional Reading


Linde SM, Badger JM, Machan JT, et al. Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery. Am J Crit Care. 2013 Nov;22(6):491-497.

Rose L, Haslam L, Dale C, Knechtel L, McGillion M. Behavioral pain assessment tool for critically ill adults unable to self-report pain. Am J Crit Care. 2013 May;22(3):246-255.

Gélinas C. Nurses’ evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool. Pain Manag Nurs. 2010 Jun;11(2):115-125.

Gélinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care. 2009 Dec;24(4):628.e7-628.e17.

Gélinas C, Fillion L, Puntillo KA. Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults. J Adv Nurs. 2009 Jan;65(1):203-216.

Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006 Jul;15(4):420-427.

Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009 Jan;37(1):58-67.

Gélinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007 Jul-Aug;23(6):497-505.

Marmo L, Fowler S. Pain assessment tool in the critically ill post-open heart surgery patient population. Pain Manag Nurs. 2010 Sep;11(3):134-140.

Gélinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. 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. Int J Nurs Stud. 2011 Dec;48(12):1495-1504.

Nürnberg Damström D, Saboonchi F, Sackey PV, Björling G. A preliminary validation of the Swedish version of the Critical-Care Pain Observation Tool in adults. Acta Anaesthesiol Scand. 2011 Apr;55(4):379-386.

Lee KI, Oh H, Suh Y, Seo W. Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool. Pain Manag Nurs. 2013 Dec;14(4):259-267.

Paulson-Conger M, Leske J, Maidl C, Hanson A, Dziadulewicz L. Comparison of two pain assessment tools in nonverbal critical care patients. Pain Manag Nurs. 2011 Dec;12(4):218-224.

Vazquez M, Pardavila MI, Lucia M, Aguado Y, Margall MA, Asiain MC. Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nurs Crit Care. 2011 Jul-Aug;16(4):178-185.

Gélinas C, Puntillo KA, Joffe A, Barr JA. A validated approach to evaluating psychometric properties of pain assessment tools for use in nonverbal critically ill adults. Semin Respir Crit Care Med. 2013 Apr;34(2):153-168.