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Pain assessment scales: numeric, visual analogue, faces, behavioural (FLACC) and in dementia

  • Assessment

Pain is measured first by what the patient says; if they cannot say, by a behavioural scale suited to their age or condition.

Updated

What it is

Pain is whatever the person experiencing it says it is. So the first choice is always self-report, with a scale the person understands. When the patient cannot report (infants, young children, cognitive disorders, sedation or mechanical ventilation), nurses use behavioural scales that score what is observed. Each scale serves a population; what matters is choosing the right one, reassessing after every intervention and comparing with the comfort-function goal agreed with the patient.

Reference values

  • Numeric: 0 (no pain) to 10 (worst pain imaginable).
  • Faces: six faces numbered 0, 2, 4, 6, 8 and 10.
  • FLACC and PAINAD: 0 to 10, scored by the observer.
  • CPOT: 0 to 8. Behavioural Pain Scale (BPS): 3 to 12.

What you need

  • A scale suited to the patient's age, cognition and ability to communicate.
  • For visual scales: the facility's card or chart.
  • For behavioural scales: observing the face, legs and body, sounds and crying, and whether the patient can be consoled.
  • The pain and function goal agreed with the patient.

How to measure it (and why)

  1. Ask whether there is pain and explore onset, location, quality, severity and timing — intensity alone does not point to the cause.
  2. Check that the patient understands the scale and ask follow-up questions if answers do not fit — a misunderstood scale gives worthless numbers.
  3. If the patient can report, use the numeric or faces scale by age and language — self-report is the reference standard.
  4. If not, choose the behavioural scale for their group (FLACC, PAINAD, CPOT or BPS) and observe before stimulating — behaviour replaces words.
  5. Do not use vital signs alone to decide whether there is pain — tachycardia or hypertension have other causes.
  6. Record the scale used, the score, the patient's words in quotation marks and the behaviour observed — another nurse must be able to repeat it.
  7. Reassess after every intervention with the same scale and compare with the goal — this shows whether treatment worked.

How to read it

  • The COMFORT behavioural scale is validated for children of all ages on mechanical ventilation.
  • The visual analogue scale is usually a 10 cm line with «no pain» at one end and «worst pain» at the other; the patient marks a point on it.
  • Stoic patients, people with cognitive disorders and people who do not speak the local language may not self-report well: observe nonverbal signs.
  • Acute pain often raises blood pressure, heart rate and respiratory rate, but these changes have other causes too.
  • In critically ill adults who cannot self-report, CPOT and BPS score behaviour; both have versions for intubated and non-intubated patients.

Next step: when to call for help

  • Call if pain does not reach the goal after the ordered intervention.
  • Call if new, very severe or different pain appears: it may signal a complication.
  • Sudden severe pain or chest pain: notify at once or call emergency services per protocol.
  • After an opioid, call for excessive drowsiness or slow breathing.

Test yourself

Think of the answer, then tap the question to see it.

What is the most reliable source for assessing pain?

The patient's self-report. Pain is what the patient says it is, and their number is accepted.

Which scale is used for an 18-month-old child in pain?

A behavioural scale such as FLACC, which scores what the observer sees in infants and young children.

Which scale is designed for people with advanced dementia?

PAINAD, a behavioural scale scored by the observer.

When is pain reassessed after an analgesic?

Usually within an hour, or at a time set by the medicine's onset and peak, per facility protocol.

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Connections

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Fundamentals (Open RN), 11.3 Pain Assessment Methods (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Nursing Fundamentals (Open RN), 11.5 Applying the Nursing Process (Comfort) (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Chanques G, et al. Psychometric comparison of three behavioural scales for the assessment of pain in critically ill patients unable to self-report. Crit Care 18(5):R160 (Critical Care (PubMed Central, open access), 2014); Todri J, et al. Assessment properties of the Visual Analogue scale, Numeric Rating Scale, Face Pain Scale, and Pain Intensity Subscale of the Brief Pain Inventory in Albanian population with low back pain. Ann Med 57(1):2601406 (Annals of Medicine (PubMed Central, open access), 2025).

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Representative model, for educational purposes only.