Modified TPPPS
| Score | ||
|---|---|---|
| 1 | Verbal expression of pain | |
| Verbal pain complaint—any word, phrase or statement that refers to pain, hurt or discomfort. | ||
| Examples: “It hurts”, “Ow”, “Oh”, “You're hurting me”. | ||
| 2 | Cry—tears in the eyes or running down the face and/or making sobbing sounds. | |
| Examples: sobbing, tears in the eyes, tears falling down cheeks. | ||
| 3 | Groan, moan, grunt—deep, low-pitched vocalisations expressing pain, hurt or discomfort. | |
| Examples: non-intelligible, low-pitched sounds. May be drawn out (moan) or abrupt (grunt). | ||
| 4 | Scream—acute, loud, high pitched cry. | |
| Examples: sharp, shrill, harsh, high-pitched vocalisation, shriek. | ||
| 5 | Facial expression of pain | |
| Open mouth, lips pulled back at corners—open mouth, lips pulled back at corners with a downward pull on the jaw. | ||
| 6 | Squint/close eyes—eyelids taut, stiff, closed or nearly closed with wrinkling of the skin at the lateral aspect of the eyes. | |
| 7 | Brow bulge/forehead furrow—bulging, creasing, or furrows above and/or between the eyebrows. | |
| 8 | Bodily expression of pain | |
| Restless motor behaviour—rub/touch painful area, or unrestrained activity. May appear random or to lack goal direction. The body and/or head is never still. | ||
| Examples: twisting and turning of torso and/or head while lying down, flailing of arms and/or legs, arching, repetitive fine motor activity. Child touches incisional area, iv site. |