Flacc Behavioral Pain Assessment Scale

FLACC Behavioral Pain Assessment Scale

CATEGORIES

SCORING

0

1

2

Face

No particular expression or smile

Occasional grimace or frown;

Frequent to constant frown, clenched jaw,

withdrawn, disinterested

quivering chin

Legs

Normal position or relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry

No cry (awake or asleep)

Moans or whimpers, occasional complaint

Crying steadily, screams or sobs; frequent

complaints

Consolability

Content, relaxed

Reassured by occasional touching, hugging,

Difficult to console or comfort

or being talked to; distractable

How to Use the FLACC

In patients who are awake: observe for 1 to 5 minutes or longer. Observe legs and body uncovered. Reposition patient or observe activity. Assess body for

tenseness and tone. Initiate consoling interventions if needed.

In patients who are asleep: observe for 5 minutes or longer. Observe body and legs uncovered. If possible, reposition the patient. Touch the body and assess

for tenseness and tone.

Face

➤

Score 0 if the patient has a relaxed face, makes eye contact, shows interest in surroundings.

➤

Score 1 if the patient has a worried facial expression, with eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed.

➤

Score 2 if the patient has deep furrows in the forehead, closed eyes, an open mouth, deep lines around nose and lips.

Legs

➤

Score 0 if the muscle tone and motion in the limbs are normal.

➤

Score 1 if patient has increased tone, rigidity, or tension; if there is intermittent flexion or extension of the limbs.

➤

Score 2 if patient has hypertonicity, the legs are pulled tight, there is exaggerated flexion or extension of the limbs, tremors.

Activity

➤

Score 0 if the patient moves easily and freely, normal activity or restrictions.

➤

Score 1 if the patient shifts positions, appears hesitant to move, demonstrates guarding, a tense torso, pressure on a body part.

➤

Score 2 if the patient is in a fixed position, rocking; demonstrates side-to-side head movement or rubbing of a body part.

Cry

➤

Score 0 if the patient has no cry or moan, awake or asleep.

➤

Score 1 if the patient has occasional moans, cries, whimpers, sighs.

➤

Score 2 if the patient has frequent or continuous moans, cries, grunts.

Consolability

➤

Score 0 if the patient is calm and does not require consoling.

➤

Score 1 if the patient responds to comfort by touching or talking in 30 seconds to 1 minute.

➤

Score 2 if the patient requires constant comforting or is inconsolable.

Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report is not possible, interpretation of pain behav-

iors and decisions regarding treatment of pain require careful consideration of the context in which the pain behaviors are observed.

Interpreting the Behavioral Score

Each category is scored on the 0–2 scale, which results in a total score of 0–10.

0

Relaxed and comfortable

4–6

Moderate pain

1–3

Mild discomfort

7–10

Severe discomfort or pain or both

From Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing,

23(3), 293–297. The FLACC scale was developed by Sandra Merkel, MS, RN, Terri Voepel-Lewis, MS, RN, and Shobha Malviya, MD, at C. S. Mott Children’s Hospital,

University of Michigan Health System, Ann Arbor, MI. Used with permission.