Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Facial Grimace and Behaviour Checklist Flow Chart

SAMPLE 4 – Facial Grimace & Behaviour Checklist Flow Charts

Name:_____________________

Time:_______________________

  

Active:  Resting:

        
              0
        No Pain

        
              2
            Mild

        
              4
      Discomforting

        
              6
       Distressing

        
              8
         Horrible

        
              8
      Excruciating

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Regular Pain Medication:_________

Rescue/PRN medication:_________

Month       
Date or Time    
Facial Score:  
10  
  8  
  6  
  4  
  2  
  0  
PRN medication  

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Facial Grimace Score:
The facial grimace scale scores the level of pain (from 0-10 on the left) as assessed by the caregiver observing the facial expressions of the resident. Assessment is done once daily or more (14 days are indicated above). This assessment of the degree of discomfort should be done at the same time every day and during the same level of activity. Note if rescue/PRN medication is given

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Behavioural Checklist

10 – always, 8 – mostly
  6 – often
  4 – occasionally
  2 – rarely
  0 – never

Date or Time       
BEHAVIOUR  
eats poorly  
tense  
quiet  
indicates pain  
calls out  
paces  
noisy breathing  
sleeps poorly  
picks  

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Behaviour Checklist:
Behaviour changes can be used to assess pain or distress, and thereby evaluate the efficacy of interventions. At the top of the scoring graph, when the specific behaviour has been observed, it can be rated from 10 (always) to 0 (never). The behaviours being rated and scored over 24 hours are listed down the left column. This chart scores 9 different behaviours over 14 days. The caregiver can expand on the checklist, i.e., rocking, screams, etc. Note if rescue/PRN medication given. Both tools may be adapted for individual use.

(The Facial Grimace & Behaviour Checklist are used with permission from Saint Joseph’s Health Centre, Sarnia. Palliative Care Research Team.) Reprinted with Permission. Brignell, A. (ed) (2000). Guideline for developing a pain management program. A resource guide for long-term care facilities, 3rd edition.

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