Also See
1. Dementia
2. End-Of-Life Pain
Criteria
1. Breathing independent of vocalization
  1. Score 0: Normal
  2. Score 1: Occasional labored breathing with short periods of Hyperventilation
  3. Score 2: Noisy, labored breathing with longer periods of Hyperventilation (e.g. Cheyne-Stokes)
2. Negative vocalization
  1. Score 0: None
  2. Score 1: Low level speech with negative or disapproving quality with occasional moan or groan
  3. Score 2: Repeated troubled calling out with loud moaning, groaning, and crying
3. Facial expression
  1. Score 0: Smiling or inexpressive
  2. Score 1: Sad, frightened or frowning
  3. Score 2: Facial grimacing
4. Body language
  1. Score 0: Relaxed
  2. Score 1: Tense, fidgeting, or distressed pacing
  3. Score 2: Rigid with fists clenched or knees pulled up. Pushing, pulling away or striking out
5. Consolability
  1. Score 0: No need for consolability
  2. Score 1: Distracted or reassured by voice or touch
  3. Score 2: Unable to console, distract or reassure
Interpretation
1. Sum the score from the 5 criteria
2. Interpret as a Pain Scale
  1. Total score 0: No pain
  2. Total score 10: Severe pain
References
1. Warden (2003) J Am Med Dir Assoc 4(1):9

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This page was written by Scott Moses, MD. This page was last revised on 11/13/2009 8:54:39 AM. This page was last published on 3/22/2010. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.