16.4: Pain Assessment

Learning Objectives

By the end of this section, you will be able to:

• Describe how to collect subjective data for a pain assessment
• Identify how to collect objective data for a pain assessment
• Recognize how to document a pain assessment

Pain is a subjective experience, which means it cannot always be observed externally. Because patients do not always outwardly display signs of pain, the pain assessment must be multidimensional (Wideman et al., 2019). Both subjective and objective data need to be included in a comprehensive pain assessment to get a complete picture of the patient’s pain.

Using a variety of assessment tools allows the patient to express the quality, type, and intensity of the pain. The nurse may use a pain rating scale and different types of questions to collect subjective data. Objective data can be collected by performing a physical assessment, measuring vital signs, and observing patient behaviors such as posture and facial expressions.

A comprehensive pain assessment is the key to adequately treating pain and is a crucial nursing skill. Without comprehensive baseline data, it can be difficult to provide effective pain management for patients.

Collecting Subjective Data

Because pain is a subjective experience, most of the collected data will be subjective (Wideman et al., 2019). Information obtained from the patient and/or family members and offers important cues from their perspective is called subjective data. A comprehensive pain assessment includes questions that assess the quality, region, severity, potential cause, timing, and aggravating and relieving factors of the patient’s pain. Asking the patient open-ended questions allows them to elaborate on their pain and helps the nurse fully understand the patient’s concerns.

The PQRSTU mnemonic is often used to remember these subjective assessment questions:

• Provocation/Palliation: What makes your pain feel worse or better?
• Quality: What does the pain feel like?
• Region: Where exactly do you feel the pain? Does it radiate?
• Severity: How would you rate your pain on scale of 0 to 10?
• Timing/Treatment: When did the pain start? How long does the pain last? Have you taken anything to relieve the pain?
• Understanding: What do you think is causing the pain?

These pain assessment questions help the nurse establish a baseline assessment of the patient’s pain.

Patient Conversations: A Comprehensive Pain Assessment Using the PQRSTU Questions

Scenario: The nurse is caring for a patient who has come into the emergency department. The nurse begins asking the patient questions about their pain including follow-up questions using PQRSTU assessment.

Nurse: Hi, my name is Sulee, and I am going to be your nurse today. What brings you in today?

Patient: My lower back is killing me. I am in so much pain.

Nurse: I am sorry to hear that. I am going to ask a few more questions about your pain so we can get an idea of what is causing it and how we can help alleviate your pain. What makes your pain worse?

Patient: Sometimes it gets worse if I am sitting for a long time.

Nurse: Do you have to sit for a long period of time often?

Patient: Yes, I sit at a desk all day at work. My back always hurts when I get home.

Nurse: What does the pain feel like?

Patient: It starts feeling sore and aching, but by the end of the day it feels like a knife is stabbing me in the back.

Nurse: Where do you feel the pain in your back?

Patient: In my lower back.

Nurse: Does the pain radiate to somewhere else in your back or in your body?

Patient: No, the pain is just across my lower back.

Nurse: How would you rate your pain on a scale of zero to ten with zero being no pain and ten being the worst pain?

Patient: Probably a seven.

Nurse: Would you rate your pain differently after sitting for a long period of time?

Patient: Yes, it’s a nine when I get home from work.

Nurse: Is the pain constant or does it come and go?

Patient: The aching is constant, but the stabbing feeling comes and goes.

Nurse: Have you taken any medication to relieve the pain?

Patient: I take ibuprofen daily and sometimes I try to lie down after work.

Nurse: Does the ibuprofen and lying down relieve the pain?

Patient: Sometimes it makes it better, but the pain never goes away.

Nurse: What do you think is causing the pain?

Patient: I was in a car accident last year and my back has hurt me ever since.

Nurse: Thank you for sharing that information. I am going to do a few other assessments so I can better understand your pain and how we can help you.

Collecting subjective data allows the nurse to begin to understand the type and location of the patient’s pain. In addition to the PQRSTU mnemonic, there are many different pain rating scales the nurse can use depending on the patient’s cognitive and developmental level.

Numeric Rating Scale

Asking a patient to use a numeric rating scale to rate the severity of their pain from 0 to 10, with “0” being no pain and “10” being the worst pain imaginable, is a common way to assess patients for pain. Most patients find the numeric rating scale easy to use and healthcare providers find the results easy to interpret (Zambon, 2020). However, the numeric rating scale may not be appropriate for all patients. Factors such as age, native language, literacy level, and cognitive ability may prohibit patients from understanding the numeric rating scale (Zambon, 2020). Some patients may be too young or cognitively delayed, or even sedated to understand how the numbers relate to the severity of pain. Patients from various cultures and native languages may not understand the numbers on the scale and may prefer a more visual pain rating scale. The nurse must ensure the patient can understand the numeric rating scale before using it. If the patient does not understand, a different assessment tool must be used.

When using a numeric rating scale, the nurse should always accept the patient’s pain for what they say it is (Wideman et al., 2019). For example, one patient with a sprained ankle may rate their pain as a 4 out of 10, while another patient with a sprained ankle may rate their pain as an 8 out of 10. Both patients are right as their interpretation of pain is subjective (Dydyk & Grandhe, 2023).

The numeric rating scale provides the nurse with the severity of a patient’s pain but does not provide any other information (Wideman et al., 2019). Additional questions must be asked to obtain a thorough pain assessment and to assess the patient’s comfort-function goal. The comfort-function goal is an individualized patient goal identifying their acceptable pain tolerance while maintaining their daily functions. This goal provides the basis for the patient’s individualized pain treatment plan and is used to evaluate the effectiveness of interventions. Each patient’s comfort-function goal will be different. For example, one patient may have a comfort-function goal of 4 out of 10 pain severity while another patient may have a goal of 0 out of 10 pain severity.

The numeric rating scale is the most common pain rating scale used in nursing due to its simplicity and ease of understanding. However, it is important for nurses to know other pain rating options to best suit individual patient needs.

Wong-Baker FACES Pain Rating Scale

The Wong-Baker FACES Pain Rating Scale is a visual tool used to evaluate pain severity. The scale uses drawings of different faces exhibiting increasing levels of pain and was created in 1983 by two pediatric healthcare workers, Donna Wong and Connie Baker, to help children express their pain. Today, the scale can be used for anyone age three and older to visually represent their pain level (Wong-Baker FACES Foundation, 2023).

Link to Learning

The Wong-Baker FACES Pain Rating Scale can be used for a variety of patients including children, patients of diverse cultures and native languages, and patients who are nonverbal due to its simplistic illustrations.

To use this scale, use the following evidence-based instructions. Explain to the patient that each face represents a person who has no pain (hurt), some pain, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the patient to choose the face that best represents the pain they are feeling.

Even though this pain rating scale was intended for children, research shows that many adult patients may prefer a visual scale. Patients with different native languages or patients who are cognitively delayed may have an easier time understanding a visual scale compared to a numeric rating scale.

McCaffrey Initial Pain Assessment Tool

The McCaffrey Initial Pain Assessment Tool is another assessment tool that helps patients express their pain. The McCaffrey Initial Pain Assessment Tool uses visual aids and questions including elements of the PQRSTU mnemonic to provide a comprehensive pain assessment. The McCaffrey tool provides a more comprehensive picture of a patient’s pain than the numeric rating scale or the Wong-Baker FACES scale.

The McCaffrey pain assessment tool includes questions pertaining to the severity, causes, contributing factors, and effects of pain. Images of the human body are included to help patients identify the exact location of their pain. There are detailed questions to help patients express the effects of pain such as accompanying emotions or symptoms, decreased quality of life, decreased physical activity, and poor sleep.

Collecting Objective Data

Collecting objective data is the second half of a comprehensive pain assessment. Objective data include things that the nurse can measure, such as vital signs and patient behavior. Objective data can help the nurse understand the patient’s pain rating and corroborate the subjective assessment data (Xu & Huang, 2020).

An objective pain assessment includes measuring vital signs, physical assessment, and observing for nonverbal indicators of pain, such as grimacing or moaning. It is especially important to observe for nonverbal indicators of pain in patients unable to self-report their pain, such as infants, children, patients who have a cognitive disorder, patients at end of life, patients who are non-English speaking, or patients who tend to be stoic due to cultural beliefs.

Nurses should be aware that pain can be exhibited through physical symptoms and patient behaviors. A pain assessment should be performed by the nurse prior to any patient interventions to determine if physical assessment findings are related to pain or something else. For example, a patient appears hunched over and guarding their stomach with reports of nausea and lack of appetite. The nurse should recognize that these symptoms could be physical signs of pain and perform a comprehensive pain assessment as the initial intervention.

Collecting objective data allows the nurse to corroborate the subjective assessment of a patient’s pain. An objective pain assessment is especially important if the patient is unable to answer questions about their pain.

Physical Assessment

A physical assessment is crucial to develop a pain treatment plan. Assessment of the location of the patient’s pain can give the nurse context to the potential cause of pain. The nurse should inspect the site of pain for any abnormalities such as swelling, lacerations, or discoloration. Areas of pain can be identified by palpating for any tenderness, swelling, or change in temperature. The nurse should note if the patient is guarding any body part as this could indicate the location of pain. Symptoms such as diaphoresis, nausea, vomiting, or lack of appetite can often be the result of pain. For example, a patient reports moderate pain on their upper back. Upon examining the patient’s back, the nurse finds bruising and tenderness upon palpation on the patient’s right shoulder. The physical assessment helps the nurse pinpoint a specific location of pain, which can help guide pain management.

Decreased daily activity can be another result of pain, especially if the patient is experiencing chronic unmanaged pain. Assessing the effect pain has on a patient’s ability to bathe, dress, prepare food, eat, walk, and complete other daily activities is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the patient’s situation. For example, for some patients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other patients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal.

Clinical Judgment Measurement Model: Recognize Cues: Identifying Physical Pain Assessment Data

The nurse is performing an initial assessment on a school-aged patient who has arrived to the hospital after being hit with a baseball. The nurse observes that the patient is guarding their right leg and is grimacing while sitting in the bed. The nurse inspects the patient’s right leg and identifies discoloration and swelling. The nurse observes the right leg is positioned at an odd angle and the patient cries out upon palpation. The patient is unable to move their leg and states “It hurts even more when I try to move.” The nurse recognizes that the odd angle and decreased mobility of the patient’s leg is most concerning. The nurse recognizes that further evaluation is needed to determine appropriate interventions for the patient’s pain.

Observe Expression and Posture

Nonverbal pain cues are an important part of an objective pain assessment. Expression and posture can indicate that a patient is in pain. Facial expressions such as grimacing, moaning, clenched teeth, or crying are ways for patients to express pain. Abnormal posture such as hunching over, contracting, rigidity, limited movement, or abnormal gait could also indicate that the patient is in pain (Figure 16.9).

Figure 16.9: A patient can exhibit physical signs of pain such as poor posture and guarding. (credit: “day 045” by Holly Lay/Flickr, CC BY 2.0)

Abnormal posture does not always indicate pain. A patient may have a stooped posture due to certain conditions, such as scoliosis or arthritis, and report no pain. The nurse should ask the patient if the abnormal posture is normal for them and always initiate a pain assessment.

Patients often exhibit abnormal posture and abnormal facial expressions together when experiencing pain. For example, a patient may exhibit a hunched posture but appear calm and relaxed and report no pain. Another patient may exhibit a hunched posture accompanied by moaning and crying. This could indicate that this is not a normal posture for the patient and may be related to pain.

When assessing patients with abnormal posture or facial expressions, the nurse should recognize that they could be potential nonverbal pain cues. Sometimes patients are in too much pain to speak or may be unable to verbally communicate. Nonverbal indicators of pain such as abnormal posture and facial expressions can be helpful to the nurse when collecting objective pain assessment data.

Inspect Skin, Muscles, and Joints

Performing an assessment of the skin, muscles, and joints can help the nurse identify specific areas of pain. Changes in skin, decreased range of motion, and an abnormal gait can all be indicative of pain. Through subjective data collection, the nurse can identify the general location of the patient’s pain. Then the nurse can assess the skin, muscles, and joints in that area to provide more data to the pain assessment.

The nurse should inspect the skin for any abnormalities such as swelling, lacerations, skin breakdown, drainage, and discoloration. Areas of pain can be identified by palpating for any tenderness, swelling, or change in temperature.

Abnormal gait, decreased range of motion, and decreased muscle strength can all be signs of pain. Just like when assessing posture and facial expressions, it is important for the nurse to remember that abnormalities in the skin, muscles, and joints do not always indicate pain. The nurse should pay particular attention to what the patient is reporting about current symptoms, as well as history of any issues. Information should be compared to expectations for the patient’s age group or that patient’s baseline. For example, an older patient may have chronic limited range of motion in the knee due to osteoarthritis, whereas a child may have new, limited range of motion due to a knee sprain that occurred during a sports activity.

Changes in skin, muscles, and joints are not always present with pain. However, these assessments can help the nurse identify a specific location of pain or potential aggravating factors.

Measure Vital Signs

Abnormal vital signs can be another nonverbal indicator of pain, especially when patients cannot show behavioral signs of pain (Ford, 2019). For example, a patient who is sedated and intubated cannot answer questions about their pain or exhibit any behaviors indicating pain. The nurse can measure vital signs along with other physical symptoms to assess pain.

Pain can cause hypertension, tachycardia, or tachypnea. Respiratory distress such as loud breathing, nasal flaring, or the use of accessory muscles can also indicate pain. Just like other nonverbal pain indicators, abnormal vital signs can also be present in the absence of pain. The nurse must use other assessment tools in addition to measuring vital signs to determine if the vital signs are related to pain (Ford, 2019).

In 1995, the American Pain Society introduced the concept of pain as the fifth vital sign to encourage providers to assess pain more frequently and prioritize pain assessments in patient care (Scher et al., 2017). There is ongoing debate as to whether treating pain as the fifth vital sign has contributed to the ongoing opioid crisis in America. Some providers believe that putting an intense focus on pain management can lead to the overprescribing of opioids, but other providers believe that pain management should be the priority in patient care. Current research shows that pain is an ongoing patient concern, and that consistent, multidimensional pain assessments are most effective in managing pain (Scher et al., 2017).

Nurses must always make pain a top priority of patient care. Nurses must include multiple assessment tools, such as measuring vital signs, in their pain assessments and individualize their assessments to meet each patient’s needs.

Assess Behavioral Cues

Behavioral cues can be important indicators of pain if the patient is unable to answer subjective assessment questions. The nurse may notice a flat affect in a patient in pain. Affect refers to the outward display of one’s emotional state. For example, a patient with a “flat affect” refers to very few facial expressions being displayed to indicate emotion (Figure 16.10).

Figure 16.10: Patients with flat affects are often associated with depression or anger, but they can also be behavioral cues of pain. (credit: “young office man suffering from backache” by centro güel/Flickr, CC BY 2.0)

The nurse must recognize that not every patient in pain will have the same behavioral cues. For example, one patient in pain may appear quiet and withdrawn while another patient may appear very angry and aggressive. A patient’s behavioral cues may not always match their subjective pain assessment. This is often the case with patients in chronic pain. For example, a patient who has cancer may rate their pain an 8 out of 10 while calmly eating lunch with their family. It is important for the nurse to remember that pain is whatever the patient says it is and that behavioral cues are only one aspect of the comprehensive pain assessment.

Documenting Pain Assessment

Documentation of the pain assessment, interventions, and reevaluation are key to effective, individualized pain management. Pain assessments should occur at regular intervals and a reassessment of pain should occur after any interventions (The Joint Commission, 2020).

When documenting subjective data, it should be in quotation marks and start with wording such as, “The patient reports…” or “The patient’s wife states …”. The nurse should document any subjective data stated by the patient including their pain score, what pain rating scale was used, and any follow-up information. The nurse should also document any behaviors, facial expressions, or physical attributes that could be related to pain. For example, the nurse would document “Patient states pain is a 7 out of 10 using the numeric rating scale. Patient is crying and grimacing. Patient states pain is in their right shoulder and has been ongoing for two days. Patient states heat relieves the pain for short periods of time. Patient’s right shoulder does not appear to have any skin breakdown or discoloration. Patient has decreased range of motion in their right shoulder when compared to the left shoulder.”

The nurse should also document the patient’s comfort-function goal and any communication with other healthcare providers. Documenting a pain assessment notifies the patient’s entire healthcare team of the assessment data. This allows the healthcare team to begin to plan interventions and further evaluation if needed. The team cannot initiate pain interventions without good assessment documentation, so this should be a top priority for the nurse.

Documenting Treatment

All pain management interventions need to be documented according to the policy of each healthcare facility. Pain management interventions can be pharmacological or nonpharmacological. Nonpharmacological treatments can include exercise, mind-body practices, psychological therapy, heat or cold, braces, and rehabilitation (Agency for Healthcare Research and Quality [AHRQ], 2019).

Any administered pain medication should be documented in the patient’s electronic medication administration record (eMAR). It is important to immediately document the intervention to avoid potential errors such as an unintended repeat dose of medication. Nonpharmacological treatments should also be documented in the patient’s medical record. Documentation of all pain interventions ensures all providers are aware of pain management strategies and that the patient is getting timely and effective treatment.

Documenting Evaluation of Treatment

All pain management interventions need to be evaluated and documented to ensure they are effective. It is important to perform a follow-up assessment in the appropriate time frame. The nurse should be aware of the different mechanisms of action for different forms of pain medications to best evaluate the effectiveness. For example, administration of intravenous pain medication should be evaluated within a shorter time frame than oral pain medication due to the different durations of action. The Joint Commission guidelines state that healthcare facilities should have policies in place regarding timeliness of pain reassessments and evaluation (The Joint Commission, 2020).

The nurse should document a new pain level and any symptoms of pain following any interventions. For example, if a patient reported a pain level of 8 out of 10 before PRN pain medication was administered, the nurse evaluates the patient’s pain level after administration to ensure the pain level is decreasing and the pain medication was effective. Effective pain management involves mutual pain goals between the healthcare team and the patient and ongoing reassessment with the patient to assess the effectiveness of pain interventions (ANA Center for Ethics and Human Rights, 2018). The nurse should compare the current pain rating to the patient’s stated comfort-function goal. If the patient states that their pain does not meet their comfort-function goal, the nurse should continue to explore pain management strategies and continue to reevaluate.