NurseSavvy Cheat SheetProcedure

Pain Rating Scales

Pain is whatever the patient says it is — self-report is the single most reliable indicator of pain. The nurse's job is to match the validated rating tool to the patient's developmental level, cognition, language, and ability to communicate, then use that SAME tool at every reassessment so the trend is meaningful. Self-report tools (Numeric Rating Scale, Visual Analog Scale, Wong-Baker FACES, Verbal Descriptor Scale) are first-line whenever the patient can reliably report. Behavioral-observation tools (FLACC, NIPS, CPOT) are reserved for patients who cannot self-report. Always document the tool used, the score, and the time.

Choose the tool by who the patient is, not by the diagnosis.

Self-report supersedes behavioral observation in the alert, oriented patient — document the patient's number even if behavioral cues seem inconsistent. NRS bands: 0 none, 1-3 mild, 4-6 moderate, 7-10 severe.

No pain
Worst pain
Mild
Moderate
Severe
0
3
4
6
7
10

/10

Select tool matched to patient
Obtain and document baseline score
record tool, score, and time
Administer ordered analgesic
Reassess 15-30 min after IV analgesic
IV opioid peaks 15-30 min
Reassess 30-60 min after oral analgesic
Reassess with the same tool
compare to baseline and patient comfort goal
Same patient, same scale, every time
switching scales destroys the trend
Set an individualized comfort goal
treat to the patient's goal, not 0/10
Report pain before it becomes severe
Quiet does not mean pain-free
children may adapt or exhaust
Report Nowescalate immediately
Unrelieved severe pain after intervention
New severe or sudden pain
possible postoperative complication
Opioid-related sedation
rising sedation precedes respiratory depression
Respiratory depression
FLACC 7 or higher in postop childFLACC ≥ 7

Clinical Pearl

When the patient can talk, believe the number — self-report is the gold standard. When they can't, the tool changes: under 3 observe (FLACC/NIPS), over 3 let them point (FACES), over 8 let them number it (0-10).

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