In this section
For acute medical and
surgical pain in children
Definition of Terms
Pain Assessment Tools
Pain assessment is crucial
if pain management is to be effective. Nurses are in a unique position to
assess pain as they have the most contact with the child and their family in
hospital. Pain is the most common symptom children experience in hospital.
Acute pain (noiciception) is associated with tissue damage and an inflammatory
response, it is self limiting of short duration and does not involve neural
Pain is multidimensional
therefore assessment must include the intensity, location, duration and
description, the impact on activity and the factors that may influence the
child’s perception of pain (bio psychosocial phenomenon) The influences that
may alter pain perception and coping strategies include social
history/issues, cultural and religious beliefs, past pain experiences and the
first pain experience. In addition family response to their child in pain can
have a negative or positive influence.
specifically seeks to provide nurses with information regarding
Pain assessment: is a multidimensional observational
assessment of a patients’ experience of pain.
Pain measurement tools: are instruments designed to measure
Pain assessment is a broad
concept involving clinical judgment based on observation of the type, significance
and context of the individual’s pain experience.
There are challenges in
assessing paediatric pain, none more so than in the pre-verbal and developmentally
disabled child. Therefore physiological and behavioural tools are used in place of
the self-report of pain. However in children with developmental disabilities there
can be incorrect assumptions and there is a risk of under-treating pain. It is
important to take behavioral cues identified by parents and caregivers to improve
pain assessment in these children.
Pain assessment in infants
and children is also challenging due to the subjectivity and multidimensional
nature of pain. The dependence on others to assess pain, limited language,
comprehension and perception of pain expressed contextually. In some children
it can be difficult to distinguish between pain, anxiety and distress.
Assessment and documenting
pain is needed in order to improve management of pain.
When assessing a child’s
level of pain careful consideration needs to be given to their
Pain measurement quantifies
pain intensity and enables the nurse to determine the efficacy of interventions
aimed at reducing pain.
A pain assessment should be
conducted during a patient’s admission. (link to Nursing
Assessment nursing clinical guideline)
Points to consider
When to assess pain?
Tools used for pain
assessment at RCH have been selected on their validity, reliability and
usability and are recognized by pain specialists to be clinically effective in
assessing acute pain. All share a common numeric and recorded as values 0-10
and documented on the clinical observation chart as the 5th vital
The importance of using the
same numeric value (0-10) is that the number relates to the same pain intensity
in each tool.
Three ways of measuring pain
Assessment Tools used at RCH
There are three main tools used for the
neonate, infant and child 3-18 years. These tools reflect a combination of
self-report and behavioural assessment.
FLACC - The acronym FLACC stands for Face,
Legs, Activity, Cry and Consolability.
The FLACC is a
pain assessment tool that uses that patient’s behaviour to assess pain
experience. It can be used for children aged between 2 months and 18 years of
age, and up to 18 years of age in children with cognitive impairment and/or
developmental disability. It can be difficult to assess pain in children with
cognitive impairment/developmental disability and in patients who are non-verbal.
Ask the parent or carer to help you explain their child’s pain behaviour to
facilitate a more accurate pain assessment.
to use FLACC:
Each category (Face, Legs
etc) is scored on a 0-2 scale, which results in a total pain score between 0
and 10. The person assessing the child should observe them briefly and then
score each category according to the description supplied.
faces pain scale
faces pain scale used self-report of pain to assess a patient’s experience of
pain. It can be used in children aged between 3 and 18 years of age, depending
upon their cognitive ability.
How to use
Explain to the patient that each face helps us
understand how much pain they have, and how this makes them feel. Face 0 is very happy because he doesn't
hurt at all (ie has no pain). Face 2
hurts just a little bit. Face 4
hurts a little more. Face 6 hurts
even more. Face 8 hurts a whole lot.
Face 10 hurts as much as you can
imagine, although you don't have to be crying to feel this bad. Ask the person
to choose the face that best describes how he is feeling.
Analogue scale is used to self-report pain to assess a patient’s experience of
pain. It can used in children aged 8 years and older, depending upon their
How to use the Visual Analogue scale?
the child to rate their experience of pain using numbers from 0 (being no pain) through to 10 (being the worst pain).
indicators in isolation cannot be used as a measurement for pain. A tool that
incorporates physical, behavioural and self report is preferred when possible.
However, in certain circumstance (for example, the ventilated and sedated
child) physiological indicators of pain can be helpful to determine a patient’s
experience of pain. These include:
Multi language Wong
Baker and Numeric tools are available if needed
PAT Tool is used in the Neonatal Intensive Care
is used for Ventilated paediatric patients assessing both pain and
information on pain management principles and assessing pain in children can be
The evidence table for this guideline can be viewed by clicking here.
Please remember to read the disclaimer.
development of this nursing guideline was coordinated by Sueann Penrose, CNC, Children's Pain Management Service,
and approved by the Nursing Clinical Effectiveness Committee. Updated November 2015.