The following table provides the criteria for the FLACC Behavioural pain scale.
| Behaviour | 0 | 1 | 2 |
|---|---|---|---|
| Face | No particular expression or smile | Occasional grimace or frown, withdrawn, disinterested | Frequent to constant quivering chin, clenched jow |
| 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, sobs, frequent complaints |
| Consolability | Content, relaxed | Reassured by touching, hugging or being talked to, distractible | Difficult to console or comfort |
Instructions
Patients who are awake:
- Observe for at least 2-5 minutes.
- Observe legs and body uncovered.
- Reposition patient or observe activity; assess body for tenseness and tone.
- Initiate consoling interventions if needed.
Patients who are asleep:
- Observe for at least 5 minutes or longer.
- Observe body and legs uncovered.
- If possible reposition the patient.
- Touch the body and assess for tenseness and tone.
Each category is scored on the 0-2 scale which results in a total score of 0-10.
Assessment of Behavioural Score:
0 = Relaxed and comfortable
1-3 = Mild discomfort
4-6 = Moderate pain
7-10 = Severe discomfort/pain
Reference: Merkel S, Voepel-Lewis T, Shayevitz JR, et al:The FLACC: A behavioural scale for scoring postoperative pain in young children. Pediatric nursing 1997; 23:293-797.
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