In this section
Note: This guideline is currently under review.
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 tissue.
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.
The guideline 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.
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
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 sign.
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:
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.
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.
FLACC has a high degree of usefulness for cognitively impaired and many critically ill children
faces pain scale 3-18yo
How to use?
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. 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 8-years and older
How to use?
Ask the child using numbers from 0 = no pain through to 10 being the worst pain
Physiological 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
Modified PAT Tool is used in the Neonatal Intensive Care Unit
Comfort B is used for Ventilated paediatric patients assessing both pain and sedation
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.
The 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 February 2019.