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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

Explain how pain scales are used to measure pain

Compare different scales
Measure pain

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

Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for
Palliative Care (2007); Beating Pain, 2nd 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 cant talk

Numeric pain rating scale

No pain Mild pain Moderate pain Severe pain Very severe pain Worst possible pain

0 1 2 3 4 5 6 7 8 9 10

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

Childrens 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 cant 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
Pain intensity FLACC score
Relaxed and comfortable 0
Mild discomfort 1-3
Moderate pain 4-6
Severe discomfort/pain 7-10

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
Cry 2
Consolability 1
Total 7

Detailed pain assessments

Detailed pain assessments are useful for treating patients with

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

PQRST assessment

Precipitating and relieving factors

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

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

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

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


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

Take home messages

Always ask about your patients 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 assessments can be a useful clinical tool in treatment and pain
Effective pain measurement leads to appropriate pain management
Health workers should therefore endeavor to accurately measure a
patients pain


African Palliative Care Association. Beating Pain: a pocketguide for pain management in
Africa, 2nd Ed. [Internet]. 2012. Available from:
African Palliative Care Association. Using opioids to manage pain: a pocket guide for
health professionals in Africa [Internet]. 2010. Available from:
Amery J, editor. Childrens Palliative Care in Africa [Internet]. 2009. Available from:
Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet].
2010. Available from: http://www.iasp-
The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.