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Behavioral pain scale

Behavioral pain scale
Item Description Score*
Facial expression Relaxed 1
Partially tightened (eg, brow lowering) 2
Fully tightened (eg, eyelid closing) 3
Grimacing 4
Upper limb movements No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with mechanical ventilation Tolerating movement 1
Coughing but tolerating ventilation for most of the time 2
Fighting ventilator 3
Unable to control ventilation 4
* Score ranges from 3 (no pain) to 12 (maximum pain).
Republished with permission of American Association of Critical-Care Nurses, from Stites M, Observational pain scales in critically ill adults, Critical Care Nurse, 2013, Vol 33, Pg 68; permission conveyed through Copyright Clearance Center, Inc.
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