Professional Documents
Culture Documents
Sand Richards
The purpose of a pain assessment tool is to understand pain from a patient’s perspective.
Pain assessments guide pain management routines and attempt to provide interventions that are
the most appropriate. Management of pain has become a standard of care for the Joint
Commission, which now requires accredited hospitals to assess and treat pain because patients
have the right to pain relief (“Health care issues”, 2009). As pain becomes the “fifth vital sign”,
health care workers struggle to find a pain assessment tool that adequately describes the
multidimensional experience of pain (Riegel, n.d.). The many pain assessment tools available
vary from strictly verbal to pictorial to numerical. The Wong-Baker Faces Scale is the pain
assessment tool designated for pediatric patients ages seven through seventeen at Mercy
Memorial Hospital (ER Triage, 2009). The following will discuss the design of the Wong-Baker
Faces Scale, the barriers and facilitators of the Wong-Baker Faces Scale, and further
Design Assessment
The Wong-Baker Faces Scale is a visual scale designed to measure pain intensity
among children and cognitively impaired adults (Hunsley and Mash, 2009, p. 557). The scale
consists of six cartoon-like faces ranging from no pain (a happy face) to severe pain (a crying,
sad face). Each of the six facial expressions is accompanied by a number, usually on a scale of
one through six (six being severe pain and one being no pain) or two through ten (ten being
severe pain and two being no pain). Under each face, there is a short description indicating what
kind of pain goes with each facial expression. When using the scale, patients are first told which
picture belongs with which intensity level of pain, and then are asked to point to the face that
Age appropriateness. The Wong-Baker Faces Scale is primarily used with children
three years of age and older. Before the age of three, infants and children must rely on their
caregiver’s interpretation of the signs and symptoms of pain based on physical signs, such as
grimacing, flailing, and crying (Riegel, n.d.). According to Fleisher, Ludwig, and Henretig
(2005), the Wong-Baker Faces Scale is a valid tool for assessing pain, especially within the ages
of four to seven because pediatric patients are not yet adept with numerical scales but are able to
easily relate their pain to facial expressions (p. 64). Though the Wong-Baker Faces Scale was
initially designed for the pediatric patient, it can also be used with adult and elderly patients,
especially those with intellectual and developmental disabilities (Bodfish, Harper, J. M. Deacon,
Acute and chronic pain. The Wong-Baker Faces Scale can be used with acute and
chronic pain; however the Wong-Baker Faces Scale is principally concerned with the intensity of
pain experienced by the patient and does not assess every possible physiological and emotional
sign and symptom that a patient might present with. According to Lois (2004), while chronic
pain demonstrates little change in physiological signs and symptoms, acute pain symptoms are
demonstrated through elevated blood pressure, elevated heart rate, elevated respiratory rate,
Behavioral symptoms of acute pain are demonstrated through moaning, rubbing the
painful site, restlessness, clenching fists, frowning, and grimacing; behavioral symptoms of
chronic pain are demonstrated more by depression, hopelessness, and listlessness. Although the
Wong-Baker Faces Scale does not directly assess the acute physiological manifestations of pain,
it has been suggested by Ferrel and Coyle (2005) that the scale has the ability to detect emotions
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such as sadness and anger, depending on how the scale was presented (p. 110). In such cases, it
may be possible to assess chronic and acute pain on a behavioral level only.
Settings. The Wong-Baker Faces Scale has been used in a variety of settings and is not
confined to hospital institutions. According to Pasero (1997), the Wong-Baker Faces Scale has
been successfully used throughout the United States in hospices, hospitals, and homes. The
portability of the Wong-Baker Faces Scale becomes apparent when laminated copies of the scale
are easily brought from room to room to measure intensities of pain experienced by patients.
Mothers of ill children or caregivers of the elderly can easily refer to the Wong-Baker Faces
Scale in the comfort of their own homes to determine when their loved ones need pain
medication. Furthermore, access and duplication rights to the Wong-Baker Faces Scale can
easily be obtained by filling out a request form on the Web site “Wong on the Web.”
Literacy level. Since the Wong-Baker Faces Scale is highly visual in nature, reading
and writing skills are not required. According to Ferrel and Coyle (2005), poorly educated
African-Americans and Caucasians prefer using the Wong-Baker Faces Scale over less pictorial
pain assessment tools (p. 110). Adults and school-aged children who are not competent with
numerical scales might feel more comfortable using a pain scale that uses faces to illustrate
different degrees of pain. The lack of literacy and numeracy needed to successfully self-report
pain using the Wong-Baker Faces Scale dramatically increases the population that the scale can
serve, ranging from children, the mentally slow, the poorly educated, and even those who speak
a foreign language.
Disabilities. Overall, the Wong-Baker Faces Scale is an ideal tool for assessing those
with a variety of disabilities when other scales of measurement are inappropriate. According to
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Bodfish et al. (2006), the Wong-Baker Faces Scale is a reliable tool for assessing pain among
patients with intellectual and developmental disabilities where self-reporting scales are still the
gold standard of pain assessments (pp. 149-172). Furthermore, the Wong-Baker Faces Scale is
an extremely versatile instrument that can be loaded in certain speech-generating programs for
those who are nonverbal or who have limited speech capabilities (“Wong-Baker Faces” n.d.).
However, certain disabilities such as blindness and sight impairments would make the
pain assessment guide less effective, since the tool relies on pictures for patients to relate their
levels of pain. Additionally, Finley (2007) suggests that the Wong-Baker Faces Scale may
convey different meanings for those who use American Sign Language because symbols similar
to the Wong-Baker Faces Scale are commonly used to convey emotions such as humor and
teasing in the deaf community (pp. 133-135). Therefore, healthcare workers need to be mindful
when using the Wong-Baker Faces Scale with those who primarily use American Sign Language
Cultural sensitivity. One of the greatest advantages of the Wong-Baker Faces Scale is its
ability to transcend race, culture, ethnicity, and language. According to Baeyer, Wood, and
Jannista (2007), instructions for administering the Wong-Baker Faces Scale have been translated
into at least 31 languages from Albanian to Wallisian, and the work toward additional
translations and revisions is current today (pp. 1-18). However, lingual sensitivity is not the only
way in which the Wong-Baker Faces Scale highlights cultural attentiveness. According to
Schiavenato, Byers, Scovanner, Windyga, and Shah (2007), the Wong-Baker Faces Scale is
more ideal than other pain assessment tools because the scale’s cartoon-like depiction does not
attempt to imitate any particular age, gender, race, or ethnicity (p. 3560). By avoiding biases that
may be present when presenting pictures of faces, the Wong-Baker Faces Scale has become a
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choice model in assessing pain. In fact, according to Luffy and Grove (2003), the Wong-Baker
Faces Scale is preferred over African-American representations of pain such as the Oucher Scale
Recommendations
Improvement of the Wong-Baker Faces Scale may take a variety of forms, including
further research into how the Wong-Baker Faces Scale can be used to assess chronic pain
behaviors through the identification of facial expressions signifying emotions such as sadness. It
would also be interesting to determine whether men have less preference for the Wong-Baker
Faces Scale, since males might perceive the cartoon’s crying face as unmasculine and may not
want to admit that their pain is at the greatest level. Findings from studies such as those
suggested may help guide health care workers in determining what kind of pain assessment tool
to use with what kind of patient and for what kind of pain.
The hallmark of the Wong-Baker Faces Scale is its reliance on a display of faces to
represent different levels of pain. It would be useful to animate the faces with a computer
program so patients could choose which animation reflects their pain the most. A soft and
soothing voice could be added to describe and clarify what each face means. Sound effects
could be added to each face to enhance the facial description. For instance, the face representing
the most intense pain could have the voice of a person crying loudly, while the face representing
no pain could have silence. There could be an option for controlling which voice the patient
heard: male or female, elderly or pediatric, and screaming or crying. In this way, healthcare
workers and families could modify the scale to fit their patients and loved ones more
appropriately.
Conclusion
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Pain management has become the responsibility of nurses, requiring them to assess and
treat pain appropriately. While self-reports of pain are the predominant tools health care
providers have, it is essential that providers of care are aware of the advantages and
disadvantages of different pain assessment tools. Health care workers must be able to decide
what pain assessment tool is most appropriate for the person they are caring for, based on the
patient’s age, cognitive and physical abilities, and cultural factors. The Wong-Baker Faces Scale
is appropriate for use with differing ages, disabilities, literacy levels and ethnicities, and in a
variety of settings. Furthermore, suggestions have been made to improve the Wong-Baker Faces
Scale, including the idea to create computer software that would enhance the scale’s utility.
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References
Baeyer, Wood, & Jannista (2007, August). Instructions for administering the Faces Pain
Scale: Revised in languages other than English. 5th ed. Retrieved from
http://painsourcebook.ca/pdfs/fps-r-multilingual-instructions-aug07.pdf
Bodfish, J. W., Harper, V.N., Deacon, J. M., Deacon, J. R., Symons, F. J. (2006). Issues
in pain assessment for adults with severe to profound mental retardation. Pain in children
Computer Faces Scale for Measuring Pediatric Pain and Mood. (Report). Feb 2009 v10 i2 p.
173(7) Journal of Pain, 10,2. p. 173(7). Retrieved from Health Reference Center
ID=HRCA
Kabes, A., Graves, J., & Norris, J. (2009, February). Further validation of the nonverbal pain
scale in intensive care patients. Critical Care Nurse, 29(1), 59-66. Retrieved from
Ferrel, B. & Coyle, N. (2005). Textbook of palliative nursing. Oxford University Press.
Hunsley, J. & Mash, E. (2008). A guide to assessments that work. Oxford University.
Joint Commission on Accreditation of Health Care. (2009). Health care issues. Retrieved
from http://www.jointcommission.org/NewsRoom/health_care_issues.htm
Luffy, R., & Grove, S. K. (2003, January-February). Examining the validity, reliability,
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http://find.galegroup.com.ezproxy.arbor.edu/gtx/start.do? prodID=HRCA
Pasero, Christine. (1997, July). Using the faces scale to assess pain. American Journal of
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painass.html
Schiavenato, M., Byers, J., Scovanner, P., Windyga, P. & Sharh, M. (2007). Is there a
http://server.cs.ucf.edu/`~vision/papers/EMBSPaperPFP.pdf
White, Lois. (2004). Foundations of nursing (2nd ed.). Delmar Cengage Learning.
Wong-Baker FACES Pain Rating Scale (n.d.). AAC AS A FAMILY. Retrieved from
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