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Nonverbal Pain Scale (NVPS) for Nonverbal Patients

Calculators  Multiple body systems
The Nonverbal Pain Scale (NVPS) for Nonverbal Patients is used to assess pain in patients who are unable to speak due to altered mental status, mechanical ventilation, sedation, etc. in critical care settings.
No particular expression or smile 0
Occasional grimace, tearing, frowning, wrinkled forehead 1
Frequent grimace, tearing, frowning, wrinkled forehead 2
Activity (movement)
Lying quietly, normal position 0
Seeking attention through movement or slow, cautious movement 1
Restless, excessive activity and/or withdrawal reflexes 2
Lying quietly, no positioning of hands over areas of the body 0
Splinting areas of the body, tense 1
Rigid, stiff 2
Physiology (vital signs)
Baseline vital signs unchanged 0
Change in SBP>20 mmHg or HR>20 bpm 1
Change in SBP>30 mmHg or HR>25 bpm 2
Baseline RR/SpO₂ synchronous with ventilator 0
RR >10 bpm over baseline, 5% decrease SpO₂ or mild ventilator asynchrony 1
RR >20 bpm over baseline, 10% decrease SpO₂ or severe ventilator asynchrony 2


Measured Factor
Level of pain
Measured Factor Disease
  • Pain
  • Moderate pain
  • Severe Pain
Measured Factor Detail
Critically ill patients are at high risk for untreated pain because they are often unable to communicate. Untreated pain might develop into chronic pain and lead to increased length of hospital stay. The NVPS quantifies pain in nonverbal patients who are unable to speak due to altered mental status, mechanical ventilation, sedation, etc. in critical care settings. It determines pain based on face expression, movement activity, guarding, vital signs, and ventilator synchrony. Scores ≤2 indicate no pain. Scores 3-6 indicate moderate pain. Scores ≥6 indicate severe pain.
Critical Care Specialist
Body System
Multiple body systems
Measured Factor High Impact
  • Severe pain

Result Interpretation

Ranges Ranges
  • Critical High: Scores ≥6
  • Normal: Score 0
  • Normal Adult Male: Score 0
  • Normal Adult Female: Score 0
  • Normal Geriatric Male: Score 0
  • Normal Geriatric Female: Score 0
Result High Conditions
  • Moderate pain
  • Severe Pain
Test Limitations
Wibbenmeyer L et al found that the NVPS correlated poorly with burn patients' self-reports of pain. Burn patients experienced background pain in addition to procedural and breakthrough pain. The authors suggested that NVPS might correlate best with procedural pain and do not correlate well with background pain. The variables in NVPS might not be sufficient to assess background pain.
References: 2


Study Validation 1
This study compared the inter-rater reliability, internal consistency, responsiveness, validity, and feasibility of three pain scales: Behavioural Pain Scale (BPS), Critical Care Pain Observation Tool (CPOT) and Non-verbal Pain Scale (NVPS). Non-parametric tests were used for statistical analysis. A total of 258 paired assessments of pain were performed in 30 patients (43% lightly sedated, 57% with delirium, 63% mechanically ventilated). The inter-rater reliability was nearly perfect for BPS and CPOT and good for NVPS. All three scales achieved satisfactory internal consistency with Cronbach-α coefficients of 0.80 for BPS, 0.81 for CPOT and 0.76 for NVPS. The BPS and CPOT exhibited the best inter-rater reliability (weighted-κ 0.81 for BPS and CPOT) and the best internal consistency (Cronbach-α 0.80 for BPS, 0.81 for CPOT), which were higher than for NVPS (weighted-κ 0.71, P <0.05; Cronbach-α 0.76, P <0.01). Responsiveness was significantly higher for BPS compared to CPOT and for POT compared to NVPS (BPS = 1.99; CPOT = 1.55; NVPS = 1.46). For feasibility, The NVPS was chosen as the preferred tool the most often (43%), followed by the BPS (33%) and the CPOT (24%), but the difference was not significant. The study concluded that all three scales demonstrated good properties; however, BPS and CPOT have significantly higher inter-rater reliability, internal consistency, and responsiveness than NVPS.
References: 3
Study Validation 2
This descriptive study compared three pain assessment tools, the Critical-Care Pain Observation Tool (CPOT), adult Nonverbal Pain Scale (NVPS), and the Faces, Legs, Activity, Cry, and Consolability scale (FLACC), in 24 nonverbal critically ill patients in a cardiac postanesthesia care unit. Data were collected immediately before the two painful events, suctioning and repositioning (turning), 1 minute after, and 20 minutes after. Cronbach alpha coefficients for internal consistency were determined. Interrater agreement by nurses was calculated using the Pearson correlation coefficient. Both the CPOT and the NVPS demonstrated high reliability (Cronbach alpha coefficients 0.89). Total agreement between raters on the NVPS of 78% for suctioning and 79% for turning. Total agreement on the CPOT was 80% for suctioning and 85% for turning. Agreement on the FLACC was 78% for suctioning and 84% for turning. Correlations between the two raters was higher with the CPOT. There was more disagreement between raters with the NVPS. The study concluded that the NVPS and the CPOT adequately capture pain in the nonverbal patients. Since the highest disagreement was in the face component of the NVPS and CPOT, with 37 out of 150 observations (25%), pictures depicting facial expressions for scoring purposes might be helpful.
References: 4
Study Validation 3
This prospective study evaluated the Critical Care Pain Observation Tool (CCPOT) and the Adult Nonverbal Scale (ANVS, also known as the Nonverbal Pain Scale (NVPS)), in 38 burn patients and compare them with patients' self-reports of pain. The numeric rating scale (NRS) and the visual analog scale (VAS) were used for patients' self-reports of pain. Logistic regression was used to compare pain scores with patient demographics, burn demographics, and administered analgesia. CCPOT and ANVS were internally consistent (Cronbach's alphas were 0.71 for CCPOT and 0.80 for ANVS). However, these scales had poor interrater reliability with Pearson correlation coefficient of 0.63 (P < .0001) for CCPOT and 0.59 (P < .0001) for ANVS. Both CCPOT and NVPS correlated poorly with patients' self-reports of pain. Both CCPOT and ANVS were able to discriminate the intensity of pain between rest and activity. Mean pain scores were 0.27 and 0.19 at rest and 0.56 and 0.44 after a noxious stimulation for CCPOT and ANVS, respectively. The pain scales showed a decrease in patient pain corresponding to the length of time after the burn. Patient demographics or evaluator experience did not influence pain ratings. Burn size was significantly associated with the pain score measured by CCPOT. In addition, both CCPOT and ANVS scales correlated well with administered analgesia. The authors conclude that CCPOT and ANVS do not accurately assess pain in burn patients because of poor interrater reliabilit and because of the disagreement between the pain scales and the patients' self-reports of pain.
References: 2
Study Additional 1
This study evaluated the effect of implementing the Nonverbal Pain Scale (NVPS) in a a critical care setting. The NVPS was chosen because it appeared to be the quickest and easiest to use. Staff and patient satisfaction questionnaires and retrospective chart reviews were used before and after implementation of NVPS. The questionnaire responses, frequency of pain documentation, and amount of pain medication given were compared from before to after implementation of NVPS. Staffs reported increased confidence in assessing pain in nonverbal patients (57% before vs 81% after implementation, P = 0.02) and increased the number of pain assessments documented by the nursing staff for nonverbal patients per day in the intensive care unit (2.2 before vs 3.4 after implementation, P = .02). Patients reported decreased pain ratings (8.5 before vs 7.2 after implementation, P = 0.04). Implementation of NVPS in a critical care setting improved patients' pain ratings, documentation by nurses, and nurses' confidence in assessing pain in nonverbal patients.
References: 5


Margaret M. Odhner
Master degree in nursing, 2006, Margaret M. Odhner, NP, is the lead nurse practitioner in the Division of Colorectal Surgery at the University of Rochester Medical Center. She used to be the Transitional Care Manager in the Department of Internal Medicine at the same hospital.


  1. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll GL. Assessing pain control in nonverbal critically ill adults. Dimens Crit Care Nurs. 2003 Nov-Dec;22(6):260-7.
  2. Wibbenmeyer L, Sevier A, Liao J, Williams I, Latenser B, Lewis R 2nd, et al. Evaluation of the usefulness of two established pain assessment tools in a burn population. J Burn Care Res. 2011 Jan-Feb;32(1):52-60.
  3. Chanques G, Pohlman A, Kress JP, Molinari N, de Jong A, Jaber S, et al. Psychometric comparison of three behavioural scales for the assessment of pain in critically ill patients unable to self-report. Crit Care. 2014 Jul 25;18(5):R160.
  4. Marmo L, Fowler S. Pain assessment tool in the critically ill post-open heart surgery patient population. Pain Manag Nurs. 2010 Sep;11(3):134-40.
  5. Topolovec-Vranic J, Canzian S, Innis J, Pollmann-Mudryj MA, McFarlan AW, Baker AJ. Patient satisfaction and documentation of pain assessments and management after implementing the adult nonverbal pain scale. Am J Crit Care. 2010 Jul;19(4):345-54; quiz 355.

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