Fundamentals · Topic 56 of 58
Pain Rating Scales
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Pain Rating Scales
Pain scales turn pain into a number you can trend. Self-report comes first; a behavioral scale is only for a patient who can't report.
Pick the tool, in order
Self-report first — behavior only when the patient can't report
Self-report · behavioral
Who gives the score: the patient or the nurse
Self-report — the patient rates it
Behavioral — the nurse scores it
Open RN also lists FLACC for any patient who can't verbalize pain. Other self-report tools: the Visual Analog Scale (a line the patient marks) and a Verbal Descriptor Scale (none, mild, moderate, severe). FACES also helps adults with a language barrier or cognitive delay. The COMFORT Behavioral Scale scores pain and sedation in mechanically ventilated children.
Read the score
0 is no pain — mild starts at 1
FLACC 1–3 = mild discomfort, 4–6 = moderate pain. PAINAD items are each 0–2, total 0–10.
Reassess at the peak
Recheck when the analgesic should be working best
Follow facility policy; Open RN rounds these to about 30 minutes IV and 60 minutes oral.
Red flags — don't wait for the score
With opioids, sedation rises before breathing slows
Technique errors
The wrong tool gives the wrong score
Behavioral tools tend to underestimate pain compared with self-report, so use self-report whenever the patient can give it.
FACES or FLACC?
The patient points (FACES) vs the nurse observes (FLACC)
| Wong-Baker FACES | FLACC | |
|---|---|---|
| Type | Self-report | Behavioral (nurse-scored) |
| Who picks the score | The patient points to the face | The nurse scores 5 behaviors |
| Age | 3 and older | About 2 months–7 years, can't self-report |
Self-report is the gold standard — the patient's number is the score. Use a behavioral scale only when the patient can't report, and the same tool every time.
Sources · Fundamentals of Nursing 30.4 Pain Assessment (OpenStax) · Nursing Fundamentals 2e 11.3 Pain Assessment Methods (Open RN) · Accuracy of the Pain Numeric Rating Scale (PMC) · Wong-Baker FACES Pain Rating Scale (Wong-Baker FACES Foundation) · FLACC Behavioral Pain Assessment Scale (Washington State DSHS) · Pain Assessment and Measurement (Royal Children's Hospital Melbourne) · PADIS Guideline (SCCM) · Pediatric Pain Assessment Scales (Palliative Care Network of Wisconsin) · PRN Range Analgesic Orders (Palliative Care Network of Wisconsin) · Nursing Fundamentals 2e 11.5 Applying the Nursing Process (Open RN) · Pain Assessment (StatPearls) · Follow your facility's protocol for pain reassessment timing.
Pain Rating Scales
A 3-year-old post-op patient can't tell you their pain is a 7 — but the wrong scale choice means you'll never catch it. Picking the right tool changes outcomes.
Pediatric and non-verbal pain assessment depends on matching the scale to the patient's developmental level and communication ability. For neonates and infants, use behavioral-physiological scales: the FLACC scale (Face, Legs, Activity, Cry, Consolability) scores 0–10 by observing five categories, each scored 0–2. It's also the go-to for cognitively impaired or sedated patients of any age. The NIPS (Neonatal Infant Pain Scale) is used for preterm and term neonates, scoring facial expression, cry, breathing pattern, arm and leg movement, and arousal. For children aged approximately 3–8 years, use self-report tools with visual anchors: the Wong-Baker FACES scale uses six cartoon faces ranging from smiling (0) to crying (10). The child points — you don't interpret the face for them. By age 8 and older, most children can reliably use a standard numeric 0–10 scale. The critical nursing action is documenting which tool was used, reassessing after intervention using the same tool, and never switching scales mid-assessment cycle.
Key Distinctions
Don't confuse FLACC (behavioral observation by the nurse) with Wong-Baker FACES (self-report by the child) — FLACC is nurse-scored, FACES requires the child to choose. Students assume crying always equals severe pain on FLACC, but consolability modifies the score — a child who stops crying with comfort scores lower. Wong-Baker is not appropriate below age 3; children under 3 lack the abstract thinking to reliably point to a face representing their pain.
Clinical Pearl
FLACC is what YOU see; FACES is what THEY tell you. Under 3? Observe. Over 3? Let them point. Over 8? Let them number it.
Adult
For adults who can self-report, the patient's own rating is the gold standard — pain is whatever the patient says it is. The Numeric Rating Scale (NRS, 0–10) is the most widely used: 0 means no pain, 1–3 mild, 4–6 moderate, 7–10 severe. The Visual Analog Scale (VAS) uses a 10-cm line where the patient marks their pain intensity; it's more precise for research but less practical bedside. The Wong-Baker FACES scale, though designed for children, is appropriate for adults with cognitive or language barriers — it does not require numeracy. The Verbal Descriptor Scale uses words (none, mild, moderate, severe) and suits patients uncomfortable with numbers. Selection depends on the patient's cognitive status, literacy, language, and developmental level. Whichever scale you choose, you must use the same scale consistently across reassessments so trends are meaningful. Document the scale used, the score, and the time. Reassess after intervention — typically 30 minutes after oral analgesics and 15 minutes after IV — using the same tool to evaluate effectiveness.
Key Distinctions
Don't confuse the NRS (0–10 verbal number) with the VAS (mark on a measured line) — they look similar but VAS requires physical marking and ruler measurement. Students often think behavioral cues override self-report in alert adults; they don't — self-report always takes priority. The FACES scale is not exclusively pediatric; it's valid for any adult with communication or cognitive limitations.
Clinical Pearl
Same patient, same scale, every time. Switching scales mid-shift turns your pain trend data into meaningless noise.
Knowledge Check
3 quick questions on the must-knows for this topic.
Which scale does the nurse score by observation, not self-report?
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Go further
- GuidePain Assessment Scales for Nursing StudentsUse PQRST and OLDCARTS with numeric, faces, and behavioral pain scales, then practice choosing the right assessment and documenting reassessment.
- GuideHead-to-Toe Assessment Order for Nursing StudentsUse a fixed nine-part route as a retrieval cue, practice transitions instead of rereading a checklist, and know when an urgent finding should interrupt the routine sequence.
- GuideHow to Study for Med-Surg: Stop Memorizing, Start ConnectingMed-surg is the first course where memorizing stops working. Start every topic at the mechanism, climb from know-it to spot-it to act-on-it, and practice questions early at the right difficulty — with a real NGN bowtie to try in-page.
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