May 20, 2007, 11:14 am

The Wong-Baker Pain Scale: It Works!


I just have one question.

Why would anyone take a perfectly good cap and ruin it with an over abundance of stripes?

You could play tic-tac-toe on these caps.

I also had another thought (my brain is smokin’ !). Two thoughts in a row on a Sunday morning!

Every time I see a nurse in an ad, they are taking something for a headache.

What message did that send out to all the young people of the time?

Be a nurse, suffer from “nerves” and a headache, receive drugs from your co-worker and get back out on the ward.

Cherry Ames never needed Bromo-Seltzer.

I’ll admit there are shifts where an aerosol form of Ativan would be nice……


Man, it’s a really good thing I’m not watching American Idol this year, or I would be totally ticked that Blake is in the top two. But I don’t care because I’m not watching it! (Okay, I did watch when Barry Gibb was on…sigh!)


Isn’t it ironic (doncha think…): I waited all year for National Nurses Week to wear my cap. Last year my hubby got sick and I was off work. This year I was on jury duty the two days I would have worn it. Somebody does not want me in that cap!


It is time to throw the verbal pain scale out the window.

There is nothing wrong with the idea of a patient rating their pain . We are all different in our ability to tolerate pain. (I have a huge tolerance for pain…unless it is dental pain, whereupon I become a whimpering puppy.)

This week I sat with a trauma patient who shattered/demolished both ankles. When she rated that pain a 7/10, I was dumbfounded. No one believed that she could only be a 7/10!

I am usually trying to make myself believe my patients are the 10/10 they describe as they talk on their cell phone and joke with their friends.

I began to question the utility of the verbal pain scale.


I’m not saying I don’t trust my patients’ truthfulness when describing their pain.

I don’t think patients understand the pain scale.

Ideally, a patient is supposed to rate their current pain when compared to the worst pain they’ve ever experienced. And yet, when I presented to the emergency department for chest pressure a year ago, I rated my pain an 8/10.

I’d had headaches that hurt worse, and yet that particular discomfort as it stood alone was an 8/10. It was a different sort of pain and I rated it without comparison to any other type of pain.

And I was able to joke and talk with the staff while I was having it. Give me a headache that is 8/10 and I am in a dark room with an ice bag on my cranium.

If a health care professional who deals with the pain scale every day could not intellectually compare the intensity of two different types of pain, how can we expect our patients to do it?



So I say drop the verbal pain scale.

Ask the patients to rate their pain using the Wong-Baker pain scale (no matter what their age). I often see adults looking to the visual scale on the wall before rating their pain.

It is amazing how well having a visual representation works for patients who need an easy understanding of what rating their pain really means.

Like yours truly, who would have rated her pain a 3/5 (or 6/10) using the above scale.

Our scale at work uses the Wong-Baker scale up to ten (with the odd numbers in between the faces).

The Wong-Baker pain scale. It isn’t just for kids anymore.


  • Peggikaye

    May 20, 2007 at 3:10 pm

    The non verbal pain scale helps … it does. But when you live with chronic pain that is severe … you learn to live life around it.

    What I live with on a daily basis … if I had a normal body, someone else waking up to my body would get their butt in the ER wondering what hit them in the middle of the night! (which, is what drives people with lupus, fibro, RA, OA etc to the doctor to GET a dianosis ..because it ain’t RIGHT!)

    If I always acted the way my pain felt, then no one would ever want to be around me.
    You soon learn
    Laugh and the world laughs with you, cry and you cry alone is far more a reality than any other saying in the world. People get tired of hearing “ouch!”

    No matter how huge the OUCH is.

  • Type-B Premed

    May 20, 2007 at 5:55 pm

    For pedi cases we use the Wong-Baker scale…so much that the smilie faces are drawn instead of numbers on the charts.

  • AlisonH

    May 20, 2007 at 10:40 pm

    It’s not just that it’s visual: it’s a face to humanly relate to when you pick one. As a patient, I’ve never seen that scale before, but it instantly seemed more useful to me than the usual 1-10. Only one change I would make: I would add a face with a single tear between 4 and 5.

  • Eleanor

    May 21, 2007 at 5:23 am

    I always tell the nurses that I have no idea where I am from 1 to 10… I’m a product of the first world, never broken a bone or given birth… how the hell do I know what a 10 is? *knocking on wood*

  • Peggikaye

    May 21, 2007 at 6:03 am

    if a broken bone or having a baby is a 10, I’m in serious trouble.

    I had natural childbirth. My youngest 9 lbs 8 3/4 oz. I’ve had more than one broken bone.

    I’ve had things that have been significantly more painful than either!!!

    People laugh at me when I say I’m needle phobic. I’m not kidding. No, seriously, I’m needle phobic. I had natural childbirth on purpose. Twice. The second time I KNEW my child was over 9 lbs and they still weren’t sticking that needle in my back! That was after one natural childbirth!!

    Childbirth and broken bones aren’t a 10 in my book. They’re … hmmm 8 maybe 8.5 at their worst.
    (yep, Kim, that’s with what I told you in the email.)
    Worst pain I’ve ever had … has to be passing a gall stone. One of those little dangerous ones. Or maybe passing a kidney stone.

    Oh … I know the worst ..10 ..absolute 20… menengitis … aseptic menengitis from IVIG! THAT …was the worst pain I’d ever felt in my life!!!! Can’t imagine worse!

  • DK

    May 21, 2007 at 11:56 am

    I can’t tell you how many nurses I’ve heard in clinical tell me how useless the 10 point pain scale is in their practice.

    I once had a patient who was obviously in severe pain tell me he was 3/10. He also told me that he rated himself as a 3 because compared to falling down a flight of icy concrete steps (which left him with an open femur fracture a few years back), he was ok.

    As a patient myself, I find the pain scale to be difficult as the frame of reference is not clear. Worst pain you can imagine is very vague. A few years ago I injured my back (improper lifting) and found myself unable to walk for a few days. I was in agony and when asked what my pain level was all I could think of was “I don’t know, it @#$^*& hurts! I took 800mg of ibuprofen and it still @#$^*& hurts!” The real problem is that I could imagine it getting much worse.

    As a nursing student, I’ve heard much negative feedback about the 10 point scale. In fact, I’m not sure I’ve heard anything good about it! IMO, something needs to change. W-B at least adds an element of frame of reference to pain.

  • laura

    May 21, 2007 at 3:25 pm

    usually the wong-baker pain scale is effective…except in the nicu setting. but it didn’t work so well when my 2nd born was in the picu (after she was hit by a 6 ton truck traveling 35 mph). at one point it was obvious to me that my girl was in pain. a mother knows these things, you know. so her nurse brought out the faces and asked zoe to point at the face to best describe how she was feeling. zoe pointed at the happy face. i looked at her nurse and stated that i still was certain my girl was in pain. her nurse agreed and administered the pain meds. later i asked zoe and she admitted that she hurt A LOT but she pointed at the happy face because she was happy that i was there with her.
    you can’t argue with that kind of logic, can you?

  • JohnS

    May 21, 2007 at 5:23 pm

    Let’s pull back to meta-analysis: Why have a pain scale at all?

    We certainly want to treat pain and relieve it if possible. We want patients to tell us if things are getting worse or getting better.

    I’ll certainly agree with the general statement that pain is “whatever the patient says it is, wherever he/she says it is, as severe as he/she says it is, lasting as long as he/she says it does.” (Delores C. Schoen)

    For our own review of effectiveness, we would like some across-patient comparable measure: we get a report of 9/10 pain, we do treatment-X, after an hour the patient reports something not 9/10.

    But we’re trying to convert a subjective report to a (sort of) objective measure. I don’t have a -better- suggestion, but that conversion just isn’t very good.

  • tundrahq

    May 24, 2007 at 10:46 am

    As a man, I would look at that those pictures and never volunteer more than a 3 unless it REALLY hurt. And that’s assuming I’d be able to focus or talk. Don’t you think men would feel pressured to “gut it out” and lie to you about the degree of pain they’re having if you showed them a picture of some crying face and then asked them to admit similar feelings?

    Maybe it’s just me, but I don’t think that scale would encourage honesty from your male patients.

  • PE Mommy

    May 27, 2007 at 12:00 pm

    I was recently in the ER twice this week with suspected appendicitis/ruptured cyst. They ruled out appendicitis, but not a cyst. Monday I was in my pcp’s office crying because it was so bad. She of course sent me to the ER immediately for appendicitis eval. They determined it was a burst cyst, but no fluid was seen on the cat scan. They did not do an US though.

    Had terrible pain all week. Saw my obgyn on Friday and that was when it started getting worse. Saw him at 145. By 945pm, I was back in the er. I wasn’t released till 10am yesterday morning. I ended up staying overnight in the ER. They ran every test to include both USs and a contrasted and non contrast cat scan. The only thing they can come up with is a cyst that ruptured and because I didn’t get a US on Monday night, they think my body reansorbed it.

    It was because of the wong baker scale that I was able to rate my pain accurately. If I had used the number scale, I would have probably said 6-7. But because I was crying and remembered the picture of the face crying, I knew it was more like 9. Because of it, they were able to treat my pain more accurately. They shot me up with dilaudid and toradol. I was much more comfortable. 🙂

  • justamom

    May 27, 2007 at 10:10 pm

    everyone’s ’10’ is different. Even the same person will feel and handle the same pain differently in any given situation. Just take a woman in labor, how would she rate her pain sitting on a triage gurney in bright lights with someone watching a blaring TV vs. in a quiet room, dim and dressed and positioned to her liking?
    I’ve had a bunch of babies, 4 without any pain medication, including induced, including on mag, had gallstones, obstructed common bile duct, awake through ERCP, three abdominal surgeries, 6 broken bones,ruptured ovarian cysts….me, my 10? having my displaced Colles fracture set while fully conscious and with not so much as a Tylenol. I was 11. Right behind that would be an autologous blood injection for tennis elbow. That was HELL.
    The scales are a good guideline or starting point. I think they are more worthwhile in seeing how effective a particular treatment for pain is than an initial assessment tool.

  • Allen

    July 26, 2008 at 12:09 am

    A few weeks ago I had a pt in triage with complaints of abd pain arrive with her father. Once vitals were completed I moved on to the pain issue. The female pt activly texting while the interview went on reported a 10/10 pain. It was obvious this pain was not intense what so ever. I quit typing and leaned back and repeated the question with a little addition. I asked her: If you had to really think hard to even notice the pain and this was a one and compare that to both arms being ripped off and that a 10 your pain is equal to losing your arms? The pt then reported a 3/10 abd pain which fit her demenor perfectly. The father became upset and said he would not have gotten out of bed for a 3/10 pain and told her to report a 10/10 pain to which the pt replied “shit daddy hes talking about my arms being ripped off” and he seemed to suddenly grasp the issue. The pt was treated and quickly released after seeing the doctor. I currently have no problem with the 10 pt pain system but I do document differently. IE pt reports 10/10 pain to ankle, on arrival pt ambulatory on injured ext without limp or abnormal gait while laughing with friends and drinking soda, wong-baker 2/10. no distress. I think everyone has had pain and some serious pain. I dont think the general public understands that you do not get the medal of honor for tolerating and pulling through ten out of ten pain with your ingrown toenail.

  • Athena

    October 1, 2009 at 10:55 am

    I am a 58-year-old woman with a formal medical diagnosis of Asperger Syndrome. It has been suggested that people on the autistic spectrum have a different experience of pain that non-spectrum people.

    Before I was diagnosed, I fell and hurt my ankle. 5 medical personnel (2 EMTs, an emergency room nurse, an x-ray technician, and a radiologist) all told me that my ankle wasn’t broken, because I wasn’t in enough pain. (I told them I was, calmly.) The x-ray showed that it was broken, in two places (one of which the radiologist had his fingers on and was flexing, asking me if it hurt: I said “Yes!”). The ends of one of the breaks were separated, I suspect during the exams in which my foot was repeatedly wrenched around into various positions.

    Many otherwise high-functioning autistic spectrum people have difficulty “reading” faces and/or facial expression. I, myself, have prospagnosia; I have difficulty recognizing faces of people I see every day, such as co-workers, and I have become aware that there are subtle emotional clues that I am incapable of perceiving.

    For us, a visual pain scale may be utterly useless, and worse than useless if medical personnel become too confident that it works in all situations, just like the medical personnel who were so serenely confident that my ankle wasn’t broken because I “wasn’t in enough pain” (despite my protestations to the contrary). (To me, on a scale of 1 to 10, a broken bone is a 4, and my monthly cramps ranged from 7 to 9.)

  • Glenda

    January 26, 2010 at 7:03 am

    Do you have a scale using 1-10 with faces?

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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