Pain is personal: it is whatever the patient says it is. But patients who cannot describe their pain, such as young children, people with dementia or those on a ventilator, are at high risk of having it missed. Choosing the right scale, and using it consistently, helps nurses treat pain properly.
Choosing the right scale
| Scale | Best for | How it works |
|---|---|---|
| Numeric rating scale (NRS) | Adults and older children who can communicate | “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, what is your pain now?” |
| Verbal rating scale | People who find numbers difficult | None, mild, moderate or severe |
| Wong-Baker FACES | Children from about 3 years, and some adults | Six faces from smiling to crying; the patient points to the one that matches |
| FLACC | Infants and young children, or people who cannot self-report | Scores Face, Legs, Activity, Cry and Consolability, each 0–2 (total 0–10) |
| PAINAD or Abbey Pain Scale | People with advanced dementia | Observes breathing, vocalisation, facial expression, body language and consolability |
| CPOT or Behavioural Pain Scale | Critically ill or ventilated adults | Observes facial expression, movement, muscle tension and ventilator compliance or vocalisation |
Ask more than a number: SOCRATES
- Site: where is the pain?
- Onset: when did it start, suddenly or gradually?
- Character: sharp, dull, burning, cramping?
- Radiation: does it spread anywhere?
- Associated symptoms: nausea, sweating, breathlessness?
- Time course: constant or comes and goes?
- Exacerbating or relieving factors
- Severity: use the chosen scale
Reassess after treatment
Check the effect of pain relief, using the same scale, about 30 minutes after IV analgesia and about 60 minutes after oral analgesia, or according to your local policy. Also assess side effects such as sedation, nausea and breathing rate, especially with opioids.
Functional goals matter
A score of zero is not always realistic. Ask what the patient needs to be able to do, such as cough, walk to the bathroom or do physiotherapy, and aim for pain that allows it.
Pitfalls to avoid
- Assuming a patient who is smiling, sleeping or talking cannot be in pain
- Assuming older adults or people from certain cultures feel less pain
- Changing scales between shifts, which makes the trend meaningless
- Not involving families, who often know a non-verbal patient’s pain signs best
- Not escalating sudden severe pain, which may signal a new complication
Related: Acute pain nursing diagnosis and care plan · Ibuprofen vs paracetamol
Sources: International Association for the Study of Pain (IASP) definition of pain (2020); Faculty of Pain Medicine and British Pain Society guidance; original validation studies of the FLACC, Wong-Baker FACES, PAINAD and CPOT tools.
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