Clinical learning · 7 min 43 sec · English captions
CPOT & RASS at the bedside
Get to know the tools for assessing pain behaviors, arousal, and agitation. Follow the bedside examples, or jump to the part you want to review.
In this video
Read the transcript
00:00 · Two familiar assessments. Two new tools.
If you're used to NVPS and SAS, here's the connection for our team at Thompson: CPOT for pain behaviors, and RASS for arousal and agitation. Each has its own descriptions and scoring. Reassess the patient with the new tool; don't convert an old number. Here's how to use both at the bedside.
00:21 · Pain and arousal
CPOT stands for the Critical Care Pain Observation Tool. RASS stands for the Richmond Agitation Sedation Scale. They answer different questions about the same patient. CPOT describes pain behaviors when reliable self-report isn't available. RASS describes arousal and agitation. Together, they help us describe the patient more clearly.
00:46 · Can the patient tell us?
For pain, the patient's own reliable report comes first. That may be spoken, written, or communicated by pointing or another reliable signal. An endotracheal tube does not automatically take self-report off the table. First, find out how the patient can communicate.
01:06 · CPOT gives behavior a structure
When a patient cannot reliably report pain, CPOT gives us a structured way to look for pain-related behaviors. We assess at rest and during care that may be painful. The context matters: a quiet minute in bed and a turn can tell different stories.
01:24 · Four areas to assess
CPOT looks at four areas: facial expression, body movement, muscle tension, and either ventilator compliance or vocalization. Each area contributes zero, one, or two points, for a total from zero to eight. We use the detailed tool to match the findings to the descriptors.
01:45 · What we can see
Facial expression may be relaxed, tense, or grimacing. Body movement may include guarding a painful area or restlessness. Look at the whole assessment. A single movement is not a diagnosis, and agitation can have several causes. CPOT helps us organize the findings.
02:05 · Muscle tension is felt
Muscle tension is something we feel during passive movement or turning. We're assessing resistance, not grip strength. Appearance alone won't tell us how much resistance is present. Respect any movement restrictions and record what you could assess.
02:23 · Ventilator or voice
For an intubated patient, the fourth area is interaction with the ventilator: for example, whether the patient tolerates ventilation or fights it. For a patient who is not intubated, listen to vocalization, such as moaning or crying out. Choose the appropriate alternative. Do not count both.
02:44 · During a turn
During a turn, an intubated patient who cannot report pain reliably grimaces with tightly closed eyes and guards the painful area. As we help with the turn, we also assess muscle tension and how the patient interacts with the ventilator.
03:01 · The findings add up
Grimacing contributes two. Guarding contributes one. The nurse feels some resistance, but it isn't strong, and can complete the movement: one point. The patient coughs but tolerates ventilation: one more. Two, plus one, plus one, plus one gives us a CPOT of five out of eight.
03:22 · A behavioral pain score
That total describes the pain behaviors observed. It does not mean the patient reports five-out-of-ten pain. Consider the behaviors and the clinical context, respond using the patient's care plan, and reassess. Changes in heart rate or blood pressure prompt assessment, but they are not CPOT points.
03:44 · RASS
Now shift to RASS. This scale describes the patient's current arousal and agitation. It runs from plus four, combative, through zero, alert and calm, down to minus five, unarousable. Compare the finding with the target prescribed for that particular patient.
04:03 · More than “restless”
On the positive side, the tool distinguishes restlessness from more pronounced agitation. Frequent non-purposeful movement, pulling at tubes, and combative behavior are different findings. Use the actual descriptors instead of choosing a number from a general impression. If safety is threatened, address that promptly and get help.
04:27 · Observe. Then assess response.
RASS follows a sequence. First, observe the patient. If the patient is not alert, use voice. Ask them to open their eyes and look at you. Only if there is no response to voice do you move to physical stimulation.
04:43 · Eye contact matters
For a patient who is not fully alert, directed eye contact matters. Eye contact to voice lasting more than ten seconds is minus one. Less than ten seconds is minus two. Movement or eye opening to voice without eye contact is minus three.
05:02 · Eye contact for 6 seconds
Imagine a drowsy patient. You ask them to open their eyes and look at you. They make directed eye contact for six seconds, then close their eyes. That's RASS minus two: light sedation. Because the patient responded to voice, there is no need to continue to physical stimulation.
05:25 · The next step
When there is no response to voice, assess the response to physical stimulation. Movement or eye opening only with physical stimulation supports minus four. No response to voice or physical stimulation supports minus five. Newly reduced responsiveness also needs clinical assessment. Medication is not the only possible cause.
05:50 · Comfort and arousal
This brings us back to why we use both tools. Pain relief and sedation are different treatment goals. After an intervention, we want to know both whether pain improved and how arousal changed. RASS does not diagnose pain or delirium. Each needs its appropriate assessment.
06:10 · Less behavior ≠ no pain
Deep sedation can suppress the behaviors we are trying to assess. Paralysis prevents a meaningful behavioral pain assessment. In those situations, absence of movement cannot establish comfort. Document the limitation, consider the clinical context, and follow the team's pain-management plan.
06:31 · The familiar nursing loop
The workflow is familiar: assess, document, respond, and reassess. Use reliable self-report whenever possible. Record the findings and their context. Then check the response at the interval appropriate to the intervention.
06:49 · The number needs context
At handoff, the number becomes more useful when we include the context. Was the assessment at rest, during turning, or after treatment? Could the patient communicate? Were there limitations? Share what you found, what you did, and what changed. Compare similar conditions when following a trend.
07:08 · CPOT & RASS
Three things to remember. The patient's reliable pain report comes first. CPOT describes pain behaviors, and RASS describes arousal and agitation. And reassessment completes the picture. Used consistently, these tools help us turn bedside observations into clearer conversations about the patient's care.
07:32 · Sources and bedside tools
For the full scale descriptions, see the CPOT and RASS bedside tools. The references also include the SCCM PADIS guidelines.