FLACC Behavioral Scale

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Fundamental Review 10-4

Fundamental Review 10-4

FLACC Behavioral Scale

This display presents two ways of demonstrating the FLACC Behavioral Scale.

	Scoring
Categories	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Face	No particular expression or smile	Occasional grimace or frown, withdrawn, disinterested	Frequent to constant frown, clenched jaw, quivering chin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 being talked to, distractible	Difficult to console or comfort
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0 to 2, which results in a total score between 0 and 10.Patients who are awake: Observe for at least 1 to 2 minutes. Observe legs and body uncovered. Reposition the patient or observe activity; assess body for tenseness and tone. Initiate consoling interventions, if needed.Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible, reposition the patient. Touch the body and assess for tenseness and tone.FaceScore 0 points if patient has a relaxed face, eye contact, and interest in surroundings.Score 1 point if patient has a worried look to face, with eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed.Score 2 points if patient has deep furrows in forehead, with closed eyes, open mouth, and deep lines around the nose/lips.LegsScore 0 points if patient has usual tone and motion to limbs (legs and arms).Score 1 point if patient has increased tone; rigidity; tense, intermittent flexion/extension of limbs.Score 2 points if patient has hypertonicity, legs pulled tight, exaggerated flexion/extension of limbs, tremors.ActivityScore 0 points if patient moves easily and freely, with normal activity/restrictions.		Score 1 point if patient shifts positions, is hesitant to move or is guarding, has tense torso, pressure on body part.Score 2 points if patient is in fixed position, rocking, has side-to-side head movements, is rubbing body part.CryScore 0 points if patient has no cry/moan (awake or asleep).Score 1 point if patient has occasional moans, cries, whimpers, sighs.Score 2 points if patient has frequent/continuous moans, cries, grunts.ConsolabilityScore 0 points if patient is calm and does not require consoling.Score 1 point if patient responds to comfort by touch or talk in 30 seconds to a minute.Score 2 points if patient requires constant consoling or is unable to be consoled after an extended time.Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report is not possible, interpretation of pain behaviors and decision making regarding treatment of pain requires careful consideration of the context in which pain behaviors were observed.Each category is scored on the 0 to 2 scale, which results in a total score of 0 to 10.Assessment of Behavioral Scale0 = Relaxed and comfortable1-3 = Mild discomfort4-6 = Moderate pain7-10 = Severe discomfort/pain

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