Better health and ageing for all Australians

Triage Quick Reference Guide

FLACC pain scale

Up to Emergency Triage Education Kit

prev pageTOC |next page

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Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jow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 GLACC: A behavioural scale for scoring postoperative pain in young children. Pediatric nursing 1997; 23:293-797.
Printed with permission © 2002, The Regents of the University of Michegan.

prev pageTOC |next page