Pain Assessment

Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is
the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these
materials, or for any errors or omissions. Last updated on January 12, 2015
Objectives

• Explain how pain scales are used to measure pain

• Compare different scales
• Measure pain

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Measuring pain

• Pain is subjective and two patients may report severity

differently from each other
• Despite the fact that pain is specific to each person, patients
can usually accurately and reproducibly indicate the severity
of their symptom by using a scale
• Scales enhance the ability of patients to communicate the
severity of their pain to health care professionals and the
ability of clinicians to communicate among themselves
• Scales also allow the clinician to assess the effect of
medications

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for
Palliative Care (2007); Beating Pain, 2 nd Ed. APCA (2012) 3
Pain scales

Scientifically validated pain scales:

• Numeric Pain Rating Scale
• Wong-Baker FACES Scale: for children who can talk
• Observation-FLACC Scale: for children who can’t talk

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Numeric pain rating scale

• Pain levels from 0-10 can be explained verbally to the patient

using a scale in which 0 is no pain and 10 is the worst possible
pain imaginable
• Patients are asked to rate their pain from 0 to 10
• Record the pain level to make treatment decisions, follow-up,
and compare between examinations

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for
Palliative Care (2007) 5
Three ways to assess pain in children

• Ask the child: FACES scale

• Ask the parent or caregiver
– Ask about previous exposure to pain, verbal pain
indicators, usual behavior or temperament
• Observe the child: FLACC scale
• The child is the best person to report their pain

Children’s Palliative Care in Africa, 2009 6

Wong-Baker FACES scale

• Use in children who can talk (usually 3 years and older)

• Explain to the child that each face is for a person who feels happy
because he has no pain, or a little sad because he has a little pain,
or very sad because he has a lot of pain
• Ask the child to pick one face that best describes his or her
current pain intensity
• Record the number of the pain level that the child reports to
make treatment decisions, follow-up, and compare between
examinations
Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for
Palliative Care (2007) 7
FLACC scale
• Use in children less than 3 years of age or older children who can’t talk
• Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score,
arriving at a score out of 10

ICPCN (2009): Adapted from Merkel et al 8

FLACC scale

• Score each of the five categories (0-2)

• Add the five scores together to get the total (out of 10)
• The total score can be related to pain intensity

Category Score
Face
Pain intensity FLACC score
Legs
Relaxed and comfortable 0
Activity
Mild discomfort 1-3
Cry
Moderate pain 4-6
Consolability
Severe discomfort/pain 7-10
Total

Guide to Pain Management in Low-Resource Settings. IASP (2010) 9

Practice using FLACC scale

• Samuel is 18 months old. You observe that he is withdrawn,

kicking his legs, and squirming. His is constantly crying or
screaming, but is calmed down by breastfeeding.
Category Score
Face 1
Legs 2
Activity 1
Cry 2
Consolability 1
Total 7

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Detailed pain assessments

• Detailed pain assessments are useful for treating patients with

pain
• Tools like the PQRST and body charts provide detailed
information on location and type of pain as well as quality and
response to treatment

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PQRST assessment

• Precipitating and relieving factors

– What makes the pain worse? What makes the pain better?

• Quality
– How would you describe the pain? What does it feel like?

• Radiation
– Is the pain in one place or does it move around your body?

• Site and Severity

– Where is your pain? On a scale of 0-10, how bad is your pain?

• Timing and Treatment history

– When did pain start? How often do you get it?
– What are the patterns of the pain? Is it constant, or does it come and go?
– Are you or have you been on treatment for the pain? Does it help?
Beating Pain, 2nd Ed. APCA (2012) 12
Body charts

Use the body chart to indicate

throbbing
areas of pain and take notes on
descriptions such as burning,
throbbing, or aching

tingling

Beating Pain, 2nd Ed. APCA (2012) 13

Take home messages

• Always ask about your patient’s pain

• Though pain is subjective, patients aged 3 and older can accurately
assess the severity of their pain
– Some patients may need some time and education by the
healthcare provider to understand how to use the different scales
– In patients younger than 3 years, objective data can be used to
assess pain
• Pain assessments can be a useful clinical tool in treatment and pain
management
• Effective pain measurement leads to appropriate pain management
• Health workers should therefore endeavor to accurately measure a
patient’s pain

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References

• African Palliative Care Association. Beating Pain: a pocketguide for pain management
in Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf
• African Palliative Care Association. Using opioids to manage pain: a pocket guide for
health professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf
• Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-
Africa-Full-Text.pdf
• Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings
[Internet]. 2010. Available from:
http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/FreeBooks/
Guide_to_Pain_Management_in_Low-Resource_Settings.pdf
• The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.
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