The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed
The nurse records the FLACC assessment as ________. (Record your answer as a whole number.)
What will be an ideal response?
ANS:
2
The FLACC scale is recorded per the following table:
0 1 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking
Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort
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