Abbey pain scale

The Abbey pain scale is for measurement of pain in people who cannot verbalise.

How to use the scale

While observing the patients, score questions 1 to 6.

Q1. Vocalisation

eg: whimpering, groaning, crying.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Q2. Facial expression

eg: looking tense, frowning, grimacing, looking frightened.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Q3. Change in body language

eg: fidgeting, rocking, guarding part of body, withdrawn.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Q4. Behavioural change.

eg: increased confusion, refusing to eat, alteration in usual patterns.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Q5. Physiological change

eg: temperature,pulse or blood pressure outside normal limits.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Q6. Physical changes

eg: skin tears, pressure areas, arthritis, contractures, previous injuries.

Absent 0   Mild 1   Moderate 2   Severe 3   ☐

Scoring

Add the scores for 1 - 6 and record here:
Total pain score ☐

Now tick the box that matches the total pain score:

0-2 No pain	3-7 Mild	8-13 Moderate	14+ Severe

Finally, tick the box that matches the type of pain:

Chronic	Acute	Acute on chronic