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Evaluating Pain in a Non-Verbal Patient

Last Modified: June 10, 2008

Dear OncoLink "Ask The Experts,"
Is there a scale that can be used to evaluate pain in a patient who is nonverbal or unresponsive and cannot use the traditional number or face scales?

Erin McMenamin, MSN, CRNP, AOCN, Pain Medicine Nurse Practitioner and Program Manager at the Abramson Cancer Center of the University of Pennsylvania, responds:

If a patient is nonresponsive, we generally assume that he or she is not responding to pain. As for nonverbal patients, we use a rating of nonverbal indicators and assess if these indicators are present at rest and/or with movement (see below). One point is given for each "yes" response, resulting in a score on a 0-12 scale.

		At Rest	With Movement
1. Vocal complaints: Non-verbal (Expression of pain, not in words, moans, groans, grunts, cries, gasps, sighs)
2. Facial Grimaces/Winces (Furrowed brow, narrowed eyes, tightened lips, jaw drop, clenched teeth, distorted expressions)
3. Bracing (Clutching or holding onto side rails, bed, tray table, or affected areas during movement)
4. Restlessness (Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still)
5. Rubbing (Massaging the affected area)
6. Vocal complaints: Verbal (Words expressing discomfort or pain, “ouch”, “that hurts”, cursing during movement, or exclamations of protest: “stop”, “that’s enough”)
TOTAL SCORE = (0-12)

In ICU patients, the RASS scale is used, which evaluates agitation and sedation.

A good reference is:

Herr, K et al. (2006) Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing, Vol 7, No 2 (June): pp 44-52.