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An ICU stay is unfortunately associated with pain and distress. For that reason, analgesics and sedatives are prescribed in large quantities to critically ill adult patients. These patients are often not able to express their pain or distress verbally due to mechanical ventilation and sedation itself. But is treatment adequate? Because no satisfactory pain and distress instrument was found, the Critically Ill Adults (CIA) scale was developed loosely based on the COMFORT scale. Nurses were trained to use this scale. In this study the CIA was validated and cut-off scores were determined to develop useful guidelines for clinical practice.