Triage Quick Reference Guide
The following table provides the criteria for the FLACC Behavioural pain scale.
|Face||No particular expression or smile||Occasional grimace or frown, withdrawn, disinterested||Frequent to constant quivering chin, clenched jow|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|
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 GLACC: A behavioural scale for scoring postoperative pain in young children. Pediatric nursing 1997; 23:293-797.
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