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Tools for Assessment of Pain in Adults

SAMPLE 4 – Facial Grimace & Behaviour Checklist Flow Charts

Name:_____________________
Time:_______________________
Active:  Resting:

 

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Regular Pain Medication:_________
Rescue/PRN medication:_________

Month
Date or Time
Facial Score:
10
8
6
4
2
0
PRN medication

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Facial Grimace Score:
The facial grimace scale scores the level of pain (from 0-10 on the left) as assessed by the caregiver observing the facial expressions of the resident. Assessment is done once daily or more (14 days are indicated above). This assessment of the degree of discomfort should be done at the same time every day and during the same level of activity. Note if rescue/PRN medication is given

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Behavioural Checklist

10 – always, 8 – mostly
6 – often
4 - occasionally
2 – rarely
0 - never

Date or Time
BEHAVIOUR
eats poorly
tense
quiet
indicates pain
calls out
paces
noisy breathing
sleeps poorly
picks

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Behaviour Checklist:
Behaviour changes can be used to assess pain or distress, and thereby evaluate the efficacy of interventions. At the top of the scoring graph, when the specific behaviour has been observed, it can be rated from 10 (always) to 0 (never). The behaviours being rated and scored over 24 hours are listed down the left column. This chart scores 9 different behaviours over 14 days. The caregiver can expand on the checklist, i.e., rocking, screams, etc. Note if rescue/PRN medication given. Both tools may be adapted for individual use.

(The Facial Grimace & Behaviour Checklist are used with permission from Saint Joseph’s Health Centre, Sarnia. Palliative Care Research Team.) Reprinted with Permission. Brignell, A. (ed) (2000). Guideline for developing a pain management program. A resource guide for long-term care facilities, 3rd edition.

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