1. Pain Assessment Update
After a comprehensive review of the literature and consulting with Pediatric pain experts, the
Pediatric Pain Task Force has selected the following pain tools for use in the Children’s
Hospital:
• NIPS
• FLACC
• FACES
• Numeric Rating Scale
Please review the descriptions of the tools. The FLACC, FACES and Numerical tools are listed
on the revised Pediatric Twenty-Four Hour Flowsheet for use in the acute care patient
population. You may be required to utilize the NIPS when floating to the intensive care units.
All tools appropriate to a given unit’s patient population will be available at the bedsides for use
in assessment.
Assessment of pain especially in preverbal or nonverbal children is challenging. The routine
use of pain assessment tools: Promotes the early recognition of the need to achieve, restore or
maintain comfort; Provides a mechanism to evaluate effectiveness of interventions; Provides a
consistent means of communication about pain between patients, families and members of the
health care team.
Clinical judgment must be utilized in selection of pain tool, pain assessment and interventions.
In addition to asking verbal patients to rate their pain, the RN should also ask the patient about
the location of pain (Where does it hurt?) and to describe the pain (What does the pain feel
like?).
Related Documents:
• Nursing Procedures
o Pain Management in Infants, Children and Adolescents (Pediatric)
o Patient Controlled Analgesia (General)
o Epidural Analgesia (General)
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•
•
Sedation Guidelines
Unit guidelines
Unit standards of care
Please complete the post-test and submit it to your
Patient Care Manager.
LRC/LF/MP
Pain Tools
2004

2. NIPS: Neonatal Infant Pain Scale
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•
•
•
An assessment tool using behavioral cues.
A six item, 0-2 point scale which results in a total score of 0-7.
Use for term neonates up to 2 months of age.
Use in combination with clinical nursing judgment. A low score on the pain scale does
not mean pain medication is not warranted.
NIPS – Neonatal Infant Pain Scale
Parameter
Facial Expression
Cry
Breathing Pattern
Arms
Legs
State of arousal
Finding
Relaxed
Grimace
No cry
Whimper
Vigorous crying
Relaxed
Change in breathing
Relaxed
Flexed/extended
Relaxed
Flexed/extended
Sleeping/awake
Fussy
Points
0
1
0
1
2
0
1
0
1
0
1
0
1
Simply add up the total points.
•
•
•
Use for pre-term infants with the addition of two physiologic parameters, heart
rate & O2 saturation.
Assess physiologic parameters and add to the score which results in
a total score of 0 – 10.
Use in combination with clinical nursing judgment. A low score on the pain scale does
not mean pain medication is not warranted.
Heart Rate
Oxygen
Saturations
Within 10% of baseline
11-20% of baseline
>20% of baseline
No additional oxygen needed
0
1
2
0
Additional oxygen required
1
LRC/LF/MP
Pain Tools
2004

3. FLACC: Face, Legs, Activity, Cry, Consolability
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•
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A five-item, three point scale that measures pain behavior on a scale of 0 - 2 which
results in a total score of 0-10.
Clinical judgment is used to interpret pain/distress behaviors considering the context
of the situation to differentiate behavioral distress from pain behavior. The higher the
score on the FLACC correlates with a higher pain/distress score.
Use for preverbal patients 2months – 4yrs, and nonverbal patients.
SCORING
CATEGORIES
0
1
2
FACE
No particular expression
or smile
LEGS
Frequent to constant
quivering chin, clenched
jaw.
Kicking, or legs drawn up.
Squirming, shifting back
and forth, tense.
Moans or whimpers;
occasional complaint
Arched, rigid or jerking.
CRY
Normal position or
relaxed.
Lying quietly, normal
position moves easily.
No cry, (awake or asleep)
Occasional grimace or
frown, withdrawn,
disinterested.
Uneasy, restless, tense.
CONSOLABILITY
Content, relaxed.
ACTIVITY
Reassured by occasional
touching hugging or being
talked to, distractible.
Crying steadily, screams
or sobs, frequent
complaints.
Difficulty to console or
comfort
WONG – BAKER FACES Pain Rating Scale
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•
•
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Six black & white cartoon faces representing various degrees of pain.
Ranges from 0 for a smiling face to 10 for a tearful face indicating “worst pain”.
Faces are scored 0, 2, 4, 6, 8, 10.
In introducing the tool to the child always point to each face using the words to describe
the pain intensity (FACE 0 is happy because he does not hurt; FACE 2 hurts a little bit;
through FACE 10 hurts the worst (advise child that ”you do not have to cry to hurt this
much”). Ask the child to choose the face that best describes his own pain and record
the score.
Caution – faces may represent experiences other than pain.
Use for patients ages 4 years through 8 years.
LRC/LF/MP
Pain Tools
2004

4. Numerical Pain Intensity Scale
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Use for patients > 9 years old, who are able to verbalize a number.
Ask the patient: “On a scale of 0 to 10, with 0 being no pain, and 10 being the worst
pain you can imagine, how much do you hurt right now?”
For patients with chronic pain, nurses must have knowledge of patient’s base line
level of pain to use this scale most effectively.
0 = No Pain, 10 = Worst Possible Pain
LRC/LF/MP
Pain Tools
2004

5. Pain Tool Post-Test
Date: _________
Unit: _____________
Name:_______________________________________________________________
1. You are caring for a 6-week-old infant 12 hours after surgery. The infant is displaying the
following: grimacing, crying that is not comforted with a pacifier or swaddling, breathing that
is shallow and rapid, arms that are flexed and rigid, restless. What is the infant’s pain score
using the NIPS pain assessment tool?
2. At what age can you use the Wong-Baker FACES Scale for pain assessment?
3. What is important to tell the patient when using the Wong-Baker tool?
4. On which patients would you use the FLACC tool to assess pain?
5. You are caring for a 5 year old patient who is non-verbal d/t CP. His face appears
withdrawn, his legs are in a normal position, he is squirming his body side to side, cries at
times but is easily comforted with his parents at the bedside. What tool is appropriate?
What score would you give his pain?
6. On what age group can you use the Numerical Rating Scale to assess pain?
7. Describe how to use the Numerical Rating Scale.
Bonus point: Rate the pain you have endured in completing this post-test and identify the tool
you used.
LRC/LF/MP
Pain Tools
2004