Figure 4: FLACC Behavioral Pain Assessment Scale
Categories
0
1
2
Face
No particular expression or smile.
Occasional grimace or frown, withdrawn, disoriented.
Frequent to constant frown, quivering chin, clenched jaw.
Legs
Normal position or relaxed.
Uneasy, restless, tense.
Kicking or legs drawn up.
Activity
Lying quietly, normal position, moves easily.
Squirming, shifting back and forth, tense. Moans or whimpers, occasional complaint. Reassured by occasional touching, hugging, or being talked to, distractible.
Arched, rigid, or jerking.
Cry
No cry (awake or asleep).
Crying steadily, screams or sobs, frequent complaints.
Consolability
Content, relaxed.
Difficult to console or comfort.
Note . From Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23 (3), 293-297, p. 293. Copyright 2002, The Regents of the University of Michigan. Used with permission. Standardized assessments
Some assessments have evidence to support the validity and reliability. The McGill Pain Questionnaire, consists of groupings of words that describe pain (e.g., sharp, sore, throbbing). This questionnaire has been found to be a “valid and reliable tool that evaluates both the quality and quantity of pain through use of unique pain descriptors” and can “evaluate the efficacy of different pain therapies” (Hawker, Mian, Kendzerska, & French, 2011, p. S243). The Pain Behavior Checklist (PBCL) is used with adults who experience chronic pain. It is a self-report checklist that addresses four dimensions: ambulation, affective distress, facial/audible expressions, and seeking help. Individuals are asked to identify the frequency for specific responses of pain. This assessment has been validated with the McGill Pain Questionnaire (Haynes, Anderson, Brown, & Jackel, 2014). The Pain Assessment Screening Tool and Outcomes Registry (PASTOR), has recently been validated within the military health system (Cook et al., 2017). The PASTOR is a combination of the
Defense and Veterans Pain Rating Scale (DVPRS) and several component measures of the Patient-Reported Outcomes Measurement Information System (PROMIS) by the National Institutes of Health (Cook et al., 2017). Areas addressed include general activity, mood, stress, sleep, anxiety, depression, fatigue, sleep, anger, interference, physical function, and social roles (Cook et al., 2017). The Checklist of Nonverbal Pain Indicators (Table 4; CNPI) is an observational tool employed for those unable to use other pain intensity instruments. While this tool does have support for validity and reliability, Ersek, Herr, Neradilek, Buck, and Black (2010), found that it has a marked floor effect when used at rest. The authors concluded that the CNPI should be used for observation of pain levels either during or immediately after treatment of a nonverbal client (Ersek et al., 2010). A zero signifies that the behavior was not observed and a 1 means the behavior was seen. Simply by observing a client’s face, leg movements, restlessness, cry, vocal complaints, and consolability, the clinician can ascertain in both adults and children whether the individual is feeling pain.
Table 4: Checklist of Nonverbal Pain Indicators (CNPI)
With Movement
At Rest
Vocal complaints – nonverbal (expression of pain demonstrated by moans, groans, grunts, cries, gasps, sighs). Facial grimaces and winces – furrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, distorted expression. Bracing – clutching or holding onto siderails, bed, tray table, or affected area during movement. Restlessness – constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still. Rubbing – massaging affected area.
Vocal complaints – verbal (expression of pain using words, e.g., “ouch” or “that hurts”; cursing during movement, or exclamations of protest, e.g., “stop” or “that’s enough”). TOTAL SCORE Instructions: 1. Write a 0 if the behavior was not observed. 2. Write a 1 if the behavior was observed even briefly during activity or rest. 3. Results in a total score between 0 and 5. 4. The interdisciplinary team in collaboration with the patient (if appropriate) can determine appropriate interventions in response to CNPI scores. Note . From Feldt, K.S. The checklist of nonverbal pain indicators (CNPI). (2000). Pain Management Nursing, 1 (1), 13-21. Reprinted with permission.
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Book Code: SWUS1524B
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