Use these tools to assess pain

A patient’s self-report of pain is the single most reliable indicator of pain and will demonstrate compliance with new pain standards from the Oakbrook, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO), according to ED sources.

"The use of a pain score demonstrates that the patient was assessed for pain, and the objective data documents the patient’s response," says Patricia Spurlock, RN, clinic administrator at Neurological Associates of Des Moines (IA) and former service line director of emergency services at Mercy Medical Center, also in Des Moines.

Get into the habit of using a variety of objective pain scales, advises Paula Tanabe, RN, PhD, CCRN, advanced practice nurse for the ED at Northwestern Memorial Hospital in Chicago. "Scales should be used for all patients experiencing pain, because this quantifies the pain," she says. "Someone with a pain score of 8 will be approached with different medications and treated differently than a patient with a score of 2 or 3."

The new standards from JCAHO require that staff take developmental concerns into account. Different pain scales are used for young children, the elderly, or developmentally delayed individuals, notes Emory Petrack, MD, MPH, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland.

By using scales, you can routinely measure with quality improvement initiatives how often pain is assessed and treated, says Tanabe. "Once nurses start objectively scoring pain, you will see increases in the amounts of analgesics administered."

Description of scales

Here are several types of pain scales and which patients they should be used for:

Numeric scales.

For adult patients, use a 0-10 numerical pain rating scale, recommends Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED at Harborview Medical Center in Seattle. "We first used it in the ED assessing chest pain, and now use it to assess the presence of any pain."

The numeric pain scale is most commonly used and most accurately portrays the adult patient’s pain, says Spurlock. "By asking the patient to rate their pain on a scale of 0 to 10, with 10 being the most severe pain, the patient will provide their perception."

In an audit done by the ED, 31% of triaged patients who did not arrive by ambulance fell within those parameters; all were triaged to a room for treatment, Spurlock reports.1 "The presenting complaints included fractures, kidney stones, back pain, migraine headaches, and vomiting."

The Wong-Baker Faces Scale.

Children ages 5 and older can rate their pain using the Wong/Baker Faces Pain Rating Scale, says Spurlock. (See scale, p. 60.) "This is a version of a numeric scale which is used for pediatric patients, as well as for those who have communication barriers. Much research has been done to validate this tool."

Descriptives are a good adjunct to those numeric scales, says Spurlock. "Using the patient’s perception of pain rather than the nurse’s perception is critical. Some patients may be very stoic, while others have a low tolerance of pain. Cultural differences and age also impact the nurses perceptions."

Verbal descriptor scale.

While most adults can use the 0-10 numeric rating scale, many cannot, notes Tanabe. "For adults who are unable to rate their pain on the 0-10 scale, the verbal descriptor is a nice alternative that most patients can use," she explains. "The elderly, in particular, do much better with the verbal descriptor scale."

Patients are shown the following words on a card: no pain, mild, discomforting, distressing, horrible, and excruciating. "The nurse should then document from 0-5. None equals 0, mild equals 1, etc.," Tanabe explains.

Oucher scale.

This scale is most appropriate for children ages 5-7. "If the child can count to 100, he or she can use the numerical scale," says Matsuoka. "If not, the child should use the Wong/Baker Faces Pain Rating Scale."

FLACC (face-legs-activity-cry-consolability) behavioral scale.

This scale can be used for children 0-5 years of age or children who cannot self-report pain. Each of the 5 categories is scored from 0-2, with the following criteria observed and rated:

Face: smiling or relaxed, occasional grimace, clenched jaw and quivering chin.

Legs: relaxed, squirming, kicking.

Activity: lying quietly; squirming and shifting back and forth; arched, rigid, or jerking.

Cry: not crying, moans or whimpers, crying steadily, screams, or sobs.

Consolability: content, relaxed; reassured by occasional touching, hugging, distractible; difficult to console or comfort. After all categories are rated, scores are added and the total score from 0-10 is determined.


1. Spurlock P. An emergency nurse’s pain management initiative: Mercy Hospital’s experience. J Emerg Nurs 1999; 25:383-385.