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Chapter 164. Pain and Sedation Scales in Adults

Lisa Doan, MD

Numerical Rating Pain Scale: 0 (no pain) to 10 (most severe pain) scale.

Figure 164-1. Visual Analog Scale (VAS)
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It is a horizontal line with no pain on the left and severe pain on the right. Patients mark along the line to represent their level of pain, which is then measured in mm. A 10 cm long line is recommended.

Figure 164-2. Wong–Baker FACES Pain Rating Scale
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This scale uses six drawings of facial features ranging from smiling (no pain) to crying (severe pain). It has been validated for use in children over 3 years of age. Reprinted with permission from Hockenberry M, Wilson D, Winkelstein ML. Wong's Essentials of Pediatric Nursing, 8th ed. Copyright © 2009, Mosby, St. Louis.

The following are commonly used scales to monitor sedation in patients receiving opioids; monitoring sedation during PCA use is especially critical.

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Pasero Opioid-Induced Sedation Scale
ScoreLevel of sedation
SSleep, easy to arouse
1Awake and alert
2Slightly drowsy, easily aroused
3Frequently drowsy, arousable
4Somnolent, hard to arouse
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Ramsay Sedation Scale
ScoreLevel of sedation
1Anxious and agitated or restless, or both
2Cooperative, oriented, and tranquil
3Responds to commands only
4Brisk response to light glabellar tap or loud auditory stimulus
5Sluggish response to light glabellar tap or loud auditory stimulus
6No response to a light glabellar tap or loud auditory stimulus
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Richmond Agitation–Sedation Scale
ScoreLevel of agitation or sedationDescription
+4CombativeCombative or violent
+3Very agitatedAttempts to remove tubes or catheters or is aggressive toward staff
+2AgitatedNonpurposeful movement or ventilator dyssynchrony
+1RestlessAnxious but nonaggressive or nonvigorous movements
0Alert and calm
−1DrowsyNot fully alert but with >10 s awakening with eye contact to voice
−2Light sedation<10 s awakening with eye contact to voice
−3Moderate sedationAny movement other than eye contact to voice
−4Deep sedationNot responsive to voice but moves with physical stimulation
−5UnarousableNot responsive to voice or physical stimulation
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1. Pasero C, McCaffery M. Safe use of a continuous infusion with IV PCA. J Perianesth Nurs. 2004 Feb;19:42–45.   [PubMed: 14770384]
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2. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974 Jun;2:656–659.   [PubMed: 4835444]
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3. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov;166(10):1338–1344.   [PubMed: 12421743]
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4. Wong DL, Baker CM. Pain in children: comparison ...

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