5.2 Verbal and Nonverbal Pain Assessment and Scales
Key Takeaways
- Self-report is the gold standard whenever the patient can give a reliable rating; use OLDCART or PQRST so the number is attached to location, quality, timing, and relieving factors.
- Match the tool to the population: Numeric Rating Scale 0–10 for verbal adults, Wong-Baker FACES when numbers are a barrier, PAINAD for advanced dementia, FLACC for nonverbal patients including children, and CPOT for nonverbal critical care.
- PAINAD scores breathing, negative vocalization, facial expression, body language, and consolability (each 0–2, total 0–10); do not substitute a family-invented number for a validated behavioral tool.
- Reassess at the expected peak of the route you used: about 15–30 minutes after a subcutaneous opioid and about 45–60 minutes after an immediate-release oral opioid.
- A patient who falls asleep after a sedative is not proven pain-free; observe grimacing, guarding, and restlessness, and reassess when the patient is arousable.
5.2 Verbal and Nonverbal Pain Assessment and Scales
Of the 26 scored Domain 2 items, a meaningful share describe a patient who cannot complete a 0–10 number — advanced dementia, severe delirium, or a nonverbal critical-care transfer onto hospice. The CHPN does not give extra credit for using the Numeric Rating Scale on someone who cannot use numbers. Self-report remains the gold standard when it is obtainable and reliable. When it is not, you switch to a validated behavioral tool, not to a guess and not to a family's invented score.
HPCC uses generic drug names and a 150-item exam. Scale questions are still clinical judgment items: vignette, then best tool or best reassessment time.
Structure the history: OLDCART and PQRST
A lone intensity number is not an assessment. Attach the number to a history using either mnemonic. They cover the same ground; pick one and use it consistently.
OLDCART
| Letter | Element | What to capture on a hospice visit |
|---|---|---|
| O | Onset | When did this episode start? Sudden fracture pain versus weeks of worsening bone ache |
| L | Location | Point to it; map radiation into a dermatome or organ-referral pattern |
| D | Duration | Seconds of shooting pain versus hours of ache; end-of-dose timing |
| C | Character | Aching versus burning versus cramping — this is how you classify type |
| A | Aggravating | Weight bearing, swallowing, inspiration, dressing change |
| R | Relieving | Position, heat, the last morphine dose, presence of a daughter |
| T | Treatment | What was tried, which route, and did it peak yet |
PQRST maps the same data: Provocation/Palliation, Quality, Region/Radiation, Severity, Timing.
On the exam, a stem that gives only a number without quality or trigger is incomplete on purpose — the correct answer is often to complete the assessment (ask character and aggravators, or apply a behavioral scale) rather than to double the long-acting opioid from a single digit.
Numeric Rating Scale (NRS) 0–10
The Numeric Rating Scale asks the patient to rate pain from 0 (no pain) to 10 (worst imaginable). It is the default for a cognitively intact adult who can self-report. Document the number and the context: at rest versus with transfer, before versus after a rescue dose. A comfort-function goal (pain low enough to turn, to visit, to pray) is more useful than chasing zero in imminently dying patients, but you still need a number or a behavioral score to know whether an intervention worked.
Do not average wildly inconsistent numbers in a delirious patient and call it an NRS. That is Section 5.3: the rating is unreliable, so you change tools.
Wong-Baker FACES
Wong-Baker FACES presents a row of faces from smiling to crying, typically scored 0–10. Use it when the patient can self-report but numbers are a barrier: some children, some adults with limited literacy, language discordance without a qualified interpreter, or mild cognitive impairment that still allows pointing to a face. It is still self-report, not a staff observation scale. Having a family member pick a face for the patient is not Wong-Baker.
PAINAD for advanced dementia
PAINAD (Pain Assessment in Advanced Dementia) is the tool HPCC-style stems reach for when an older adult with advanced dementia cannot use numbers or faces reliably. Five items are scored 0–2 (total 0–10):
- Breathing independent of vocalization (normal versus noisy, labored, or Cheyne–Stokes-pattern distress)
- Negative vocalization (none versus moaning, calling out, crying)
- Facial expression (smiling or inexpressive versus frown, grimace)
- Body language (relaxed versus tense, pacing, rigid, fists clenched)
- Consolability (no need to console versus unable to be consoled)
A score of 4 or higher is commonly treated as moderate pain warranting intervention, then reassessment with the same tool. PAINAD is not an ICU ventilator tool and not a pediatric first-line tool.
FLACC
FLACC scores Face, Legs, Activity, Cry, Consolability, each 0–2 (total 0–10). It was built for infants and young children who cannot self-report and is also used for nonverbal adults when a behavioral scale is needed and PAINAD is not the better population match. On CHPN (an adult hospice and palliative RN exam) expect FLACC when the stem describes a nonverbal adult who is not specifically an advanced-dementia long-stay patient, or a developmentally delayed adult. Do not pick FLACC as the first choice for a verbal adult who can use the NRS.
CPOT in ICU and nonverbal critical care
The Critical-Care Pain Observation Tool (CPOT) is for nonverbal critically ill adults — intubated, deeply sedated, or otherwise unable to self-report in an ICU-level setting. Four domains (facial expression, body movements, muscle tension, and either ventilator compliance or vocalization) total 0–8. A score ≥ 3 suggests unacceptable pain. CHPN candidates see CPOT when the vignette is a critical-care or step-down nonverbal patient, not a typical home-hospice dementia visit. Using CPOT on an ambulatory hospice patient with Alzheimer disease is the wrong population match; that stem wants PAINAD.
Nonverbal cues when no scale has been applied yet
Before a named tool, the exam still expects you to observe:
- Facial grimacing, brow furrow, clenched jaw
- Guarding a region, drawing up knees, resisting turns
- Restlessness, picking, trying to get out of bed
- Moaning with movement, split-second breath-holding during a dressing change
These cues start the assessment. They do not replace PAINAD, FLACC, or CPOT when those tools fit. They also do not prove the absence of pain if they are missing — chronic and dying patients often have few autonomic signs.
Reassess after the intervention, at the peak of the route
Giving morphine and charting the number the next morning is not evaluation. Match reassessment to onset and peak:
| Route you just used | Typical window to reassess at expected peak |
|---|---|
| Intravenous opioid | About 10–20 minutes |
| Subcutaneous opioid | About 15–30 minutes |
| Oral immediate-release opioid | About 45–60 minutes |
| Transdermal fentanyl | Many hours; not an acute-peak check after a patch change |
If pain is unchanged at peak, the plan is incomplete: dose, interval, route, mechanism-matched adjuvant, or a non-physical total-pain domain. If you reassess before peak, you will falsely conclude the dose failed and stack sedating doses.
Sleeping after a sedative is not a pain score
A patient who just received lorazepam or another sedative and is now asleep has not demonstrated analgesia. Sedation can mask grimacing and stop a verbal report. Do not document pain-free based on sleep alone. Observe residual cues (still guarding, still frowning), reassess when arousable, and use a behavioral scale if the patient cannot report. Families often equate sleep with comfort; your job on the exam is to refuse that assumption when a sedative was just given.
Scale → population matching table
| Scale | Score range | Population on CHPN stems | Basis |
|---|---|---|---|
| Numeric Rating Scale 0–10 | 0–10 | Cognitively intact adult who can self-report | Self-report |
| Wong-Baker FACES | 0–10 | Patient who can point to a face but struggles with abstract numbers | Self-report |
| PAINAD | 0–10 | Advanced dementia; cannot reliably self-report | Behavior |
| FLACC | 0–10 | Nonverbal child or nonverbal adult when FLACC is the available validated tool | Behavior |
| CPOT | 0–8 | Nonverbal ICU / critical-care patient (ventilated or not) | Behavior |
Exam trap: Self-report beats a behavioral tool whenever self-report is reliable. Behavioral tools beat family guesses. The wrong scale for the population is a wrong answer even if you later pick a correct opioid.
An 82-year-old hospice patient with advanced Alzheimer disease cannot use numbers or point reliably to faces. She moans when turned and grimaces during perineal care. Which tool should the CHPN candidate apply?
You give immediate-release oral morphine for a pain flare. When should you reassess at the expected peak of that dose?
A patient received lorazepam for anxiety 20 minutes ago and is now asleep. The family says the pain must be gone because he is sleeping. What is the correct assessment stance?