Odhner et al developed a pain scale for critically ill adults who are unable to verbalize. The scale was based on the FLACC scale used in children (see Chapter 44). The authors are from Strong Memorial Hospital in Rochester, New York.
Parameters:
(1) facial expression
(2) activity and movement
(3) guarding
(4) vital signs (physiologic I)
(5) physiologic responses to pain (physiologic II)
|
Parameter |
Finding |
Points |
|
facial expression |
no particular expression or smile |
0 |
|
|
occasional grimace, tearing, frowning, wrinkled forehead |
1 |
|
|
frequent grimace, tearing, frowning, wrinkled forehead |
2 |
|
activity and movement |
lying quietly, normal position |
0 |
|
|
seeking attention through movement |
1 |
|
|
slow cautious movement |
1 |
|
|
restless, excessive activity |
2 |
|
|
withdrawal reflexes |
2 |
|
guarding |
lying quietly; no positioning of hands over areas of body |
0 |
|
|
splinting areas of body, tense |
1 |
|
|
rigid, stiff |
2 |
|
vital signs |
stable over past 4 hours |
0 |
|
|
change over past four hours (see below) |
1 |
|
|
change over past four hours (see below) |
2 |
|
pain response |
skin warm and dry |
0 |
|
|
perspiring, flushing, dilated pupils |
1 |
|
|
pale and diaphoretic |
2 |
|
Change in these Vital Sign |
1 Point for One or More of the Following |
2 Points for One or More of the Following |
|
systolic blood pressure |
21 - 30 mm Hg |
> 30 mm Hg |
|
heart rate |
21 - 25 beats per minute |
> 25 beats per minute |
|
respiratory rate |
11 - 20 breaths per min |
> 20 breaths per min |
overall score =
= SUM(points for all 5 parameters)
Interpretation:
• minimum overall score: 0
• maximum overall score: 10
• The higher the score the more severe the apparent pain.
Purpose: To determine the level of pain being experienced by a nonverbal adult in the intensive care unit (ICU) using the scale of Odhner et al.
Specialty: Sports Medicine & Rehabilitation
Objective: severity, prognosis, stage
ICD-10: F45.4,
