NCLEX Quick Tips

Pain Assessment Scales

 Nurse Lorraine has just passed the nursing board exam and is now looking for a job. She has spent a great deal of time dropping curriculum vitaes in hospitals and clinics and luckily, her hard work has paid off as she is now scheduled for an interview/skills assessment. However, she feels troubled as from what she’s heard from others, skills assessment in the said hospital is difficult. She has to memorize and perform the use of different pain assessment scales, for example.

Yes, she is aware that pain assessment is considered as the fifth vital sign, and that there are several pain assessment tools present nowadays, but, with her being a fresh graduate and having little experience in using those in the clinical setting, she couldn’t remember each of them as well as how or when they are used very well.

With her not very familiar with those scales, she tells herself to review and revisit the concepts she has learned in nursing school for her to learn how to answer questions that may be thrown at her and to perform the skill better. But wait, what should she study first? Or more specifically, what are examples of tools used when assessing pain?

Wong-Baker FACES Pain Rating Scale

The Wong-Baker Faces Pain Rating Scale, which was developed by Donna Wong and Connie Baker, is a scale which shows a series of faces ranging from a happy face at 0, “No hurt” to a crying face at 10 “Hurts worst”.

When utilizing this scale, one should first explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can image, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.

This rating scale is recommended for persons age 3 years and older.

0-10 Numeric Pain Scale

This is one of the most commonly used pain scales in healthcare. It offers the individual in pain to rate their pain score and is designed to be used by those over the age of 9. In the numerical scale, the user has the option to verbally rate their scale from 0 to 10 or to place a mark on a line indicating their level of pain. 0 indicates the absence of pain, while 10 represents the most intense pain possible.

The Numerical Rating Pain Scale allows the healthcare provider to rate pain as mild, moderate or severe, which can indicate a potential disability level.

FLACC Scale

FLACC stands for face, legs, activity, crying and consolability. The FLACC pain scale was developed to help medical observers to assess the level of pain in children who are too young to cooperate verbally and can also be used in adults who are unable to communicate.

It is based on observations made regarding the patient’s face, the position of their legs, their actions, and whether they are calm or consolable. Zero to two points are assigned for each of these 5 areas of observation.

The overall score is recorded as follows:

0 = Relaxed and comfortable

1-3 = Mild discomfort

4-6 = Moderate pain

7-10 = Severe discomfort/pain

By recording the FLACC score periodically, the medical personnel can gain some sense of whether the patient’s pain is increasing, decreasing or stable.

CRIES Scale

This pain assessment tool is often used in the neonatal healthcare setting. CRIES is an observer-rated pain assessment tool which is performed by a healthcare practitioner such as a nurse or physician and assesses crying, oxygenation, vital signs, facial expression, and sleeplessness.

The CRIES Pain Scale is generally used for infants 6 months old and younger.

COMFORT Scale

The COMFORT Scale is a pain scale that may be used by a healthcare provider when a person cannot describe or rate their pain. Some of the common populations this scale might be used with include:

  • children
  • cognitively impaired adults
  • adults whose cognition is temporarily impaired, by medication or illness
  • the learning disabled
  • sedated patients in an ICU or operating room setting

The COMFORT Scale provides a pain rating between 9 and 45.

McGill Pain Scale for Pain Assessment

The McGill Pain Questionnaire consists of groupings of words that describe pain. When using this scale, the person rating their pain ranks the words in each grouping such as words like tugging, sharp and wretched.

Once the person has rated their pain words, the administrator assigns a numerical score, called the Pain Rating Index.

Pain Quality Assessment Scale (PQAS)

The Pain Quality Assessment Scale (PQAS) is a 20-item instrument developed to quantify the quality and intensity of pain associated with all types and categories of pain problems, including both nociceptive and neuropathic pain. The specific items added assess tender, numb, electrical, tingling, radiating, throbbing, aching, shooting, cramping and heavy pain qualities.

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