FLACC Scale
FLACC Scale
FLACC Scale
0 1 2
0 1 2
0 1 2
0 1 2
In patients who are asleep: observe for 5 minutes or longer. Observe body and legs uncovered. If possible,
reposition the patient. Touch the body and assess the tenseness and tone.
In patients with cognitive impairment, obtain parent input on individualized behaviors for each category
prior to assessment. Examples of behaviors may include agitation, verbal outbursts, tremors, shivering,
hypertonicity or increased spasticity, breath holding, and gasping, and are italicized below.
Face
• Score 0 if the patient has a relaxed face, makes eye contact, shows interest in surrounding
• Score 1 if the patient has a worried facial expression, with eyebrows lowered, eyes partially
closed, cheeks raised, mouth pursed
• Score 2 if the patient has deep furrows in the forehead, closed eyes an open mouth, deep lines
around nose and lips; distressed-looking face; expression of fright or panic
Legs
• Score 0 if the muscle tone and the motion in the limbs are normal
• Score 1 if patient has increased tone, rigidity, or tension; if there is intermittent flexion or
extension of limbs; occasional tremors
• Score 2 if the patient has hypertonicity, the legs are pulled tight, there is exaggerated flexion or
extension of the limbs, tremors; marked increase in spasticity, constant tremors or jerking
Activity
• Score 0 if the patient moves easily and freely, normal activity or restrictions; regular, rhythmic
respirations
• Score 1 if the patient shifts positions, appears hesitant to move, demonstrates guarding, a tense
torso, pressure on a body part; tense or guarded movements; mildly agitated (e.g. head back and
forth, aggression); shallow, splinting respirations, intermittent sighs
• Score 2 if the patient is fixed in a position, rocking; demonstrates side-to-side head movement or
rubbing of a body part; severe agitation; head banging; shivering (not rigors); breath holding,
gasping or sharp intake of breaths, severe splinting
Cry
• Score 0 if the patient has no cry or moan, awake or asleep
• Score 1 if the patient has occasional moans, cries, whimpers, sighs; occasional verbal outburst or
grunt
• Score 2 if the patient has frequent or continuous moans, cries, grunts; repeated outbursts, constant
grunting
Consolability
• Score 0 if the patient is calm and does not require consoling
• Score 1 if the patient responds to comfort by touching or talking in <30 seconds to 1 minute
• Score 2 if the patient requires constant comforting or is inconsolable; pushing away caregiver,
resisting care or comfort measures
Each category is scored on the 0-2 scale, which results in a total possible score of 0-10. 0 = Relaxed and
Comfortable, 1-3 = Mild discomfort, 4-6 = Moderate pain, 7-10 = Severe pain or discomfort or both