Pain Assessment Methods

Effective pain assessment is essential for understanding a patient’s experience and guiding appropriate management strategies. Nurses use a variety of methods to evaluate pain, including self-reports, observational tools, and physical assessments. These methods help identify the type, intensity, and impact of pain on a patient’s daily life. A thorough assessment ensures that pain management interventions are tailored to the individual’s needs, promoting better outcomes and improved quality of care.

Subjective Pain Assessment Methods

Asking a patient to rate the severity of their pain on a scale from 0 to 10, with “0” being no pain and “10” being the worst pain imaginable is a common question used to screen patients for pain. This question can be used to initially screen a patient for pain, but a thorough pain assessment is required. Additionally, the patient’s comfort-function goal must be assessed and documented. This individualised comfort-function goal provides the basis for the patient’s pain treatment plan and is used to evaluate the effectiveness of interventions and make changes as needed.

PQRSTU

The PQRSTU mnemonic is a systematic approach used to collect key information required for a comprehensive pain assessment. The framework guides the nurse through the key aspects of a pain evaluation by considering the following:

• Provocative/palliative factors: Factors that bring the pain on, or make it worse and factors that reduce  or alleviate the pain.
• Quality/quantity: Characteristics and nature of the pain.
• Region/radiation: Location and spread of pain.
• Severity: Intensity level of the pain.
• Timing: Onset and duration of the pain.
• Understanding: Patient’s interpretation of the pain.

When interviewing the patient nurses use open-ended questions from this framework to gather detailed information, if responses seem inconsistent, they then employ follow-up questions to validate the data. For example, if a patient states that “the pain is tolerable” but rates the pain as a “7” on a 0 to 10 pain scale, further questioning may reveal the pain varies with activity, such as being higher during physiotherapy but is manageable during rest. This additional information allows the nurse to customise pain management strategies to the patient’s needs and therefore provide more effective interventions. Sample questions when using the PQRSTU assessment are included below.

FACES Scale

The FACES scale is a visual tool for assessing pain in children and others who cannot quantify the severity of their pain on a scale of 0 to 10. See Figure 2 for the FACES Pain Rating Scale. 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 person to choose the face that best represents the pain they are feeling. Note that the person reports which face best represents how they are feeling, and the nurse does not select a face based on how the person appears to feel.

 

FLACC Scale

The FLACC scale (i.e., the Face, Legs, Activity, Cry, Consolability scale) is a measurement used to assess pain for children between the ages of two months and seven years or individuals who are unable to verbally communicate their pain. The scale has five criteria, which are each assigned a score of 0, 1, or 2. The scale is scored in a range of 0 to 10 with “0” representing no pain. See Table 2 for the FLACC scale. Like all behavioural tools, the FLACC cannot distinguish between pain and other forms of distress. Think critically when interpreting behaviours that may be pain-related and when making treatment decisions based on the FLACC total score. You should observe the patient for at least two to five minutes before assigning a score.

Table 2: The FLACC Scale

Criteria	Score 0	Score 1	Score 2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn, or uninterested	Frequent to constant quivering chin; clenched jaw
Legs	Normal position or relaxed	Uneasy, restless, or tense	Kicking or legs drawn up
Activity	Lying quietly, normal position, and moves easily	Squirming, shifting, back and forth, or tense	Arched, rigid, or jerking
Cry	No cry (awake or asleep)	Moans or whimpers or occasional complaint	Crying steadily, screams or sobs, or frequent complaints
Consolability	Content and relaxed	Reassured by occasional touching, hugging, or being talked to; distractible	Difficult to console or comfort

Pain Assessment in Advanced Dementia (PAINAD) Scale

The Pain Assessment in Advanced Dementia (PAINAD) Scale is a simple, valid, and reliable instrument for assessing pain in noncommunicative patients with advanced dementia. See Table 3 for the items included on the scale. Each item is scored from 0 to 2, and when totalled, the score can range from 0 (no pain) to 10 (severe pain).

Table 3: The PAINAD Scale

Item	0	1	2
Breathing independent of vocalisation	Normal	Occasional laboured breathing. Short period of hyperventilation.	Noisy laboured breathing. Long period of hyperventilation. Cheyne-Stokes respirations.
Negative vocalisation	None	Occasional moan or groan. Low-level speech with a negative or disapproving quality.	Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial Expression	Smiling or inexpressive	Sad. Frightened. Frown.	Facial grimacing.
Body language	Relaxed	Tense. Distressed pacing. Fidgeting.	Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.
Consolability	No need to console	Distracted or reassured by voice or touch.	Unable to console, distract, or reassure.

Download the full PAINAD scale from The Hartford Institute for Geriatric Nursing.

Pain Assessment in Patients with Impaired Cognition (PAIC15)

The PAIC15 Scale is a recently developed tool for use with individuals who are cognitively impaired, particularly those with dementia. It was developed through a large multidisciplinary collaboration of clinical, research, and methodological experts, including nurses, from several European countries. The team of experts developed this new meta-tool over a period of seven years, during which team members empirically evaluated items from all existing pain-related observational tools and reached a consensus on the 15 most promising items, based on validity and reliability.

As shown in the tool, the PAIC15 includes 15 descriptors with five items each for:

• Facial expression
• Body movements
• Vocalisation.

The PAIC15 is helpful when you have limited time with the patient, as you can quickly assess pain either at rest or with movement. Download the full PAIC15 scale.

Objective Pain Assessment Methods

It is always important to perform an objective assessment following a subjective assessment, but this is particularly the case for infants, young children, and non-verbal patients who may have difficulties with self-reporting.

The type of objective assessment used will depend on the location of the pain, the related body systems, and the acuity of the situation. Focused assessments of the body system may be necessary. For example, if a patient describes knee pain, you should do a focused assessment of the musculoskeletal system. If a patient describes chest pain, you should do a focused assessment of the cardiovascular system, the respiratory system, and possibly the musculoskeletal system.

The objective assessment does not follow a specific order; it depends on the acuity of the situation and the stability of the patient. Common components of an objective assessment of pain include the following.

Full Set of Vital Signs

Vital signs can be affected by pain, particularly acute pain. Collection and assessment of vital sign data may provide important information related to the patient’s stability and the potential for clinical deterioration. Vital signs are also an important component of pain tools that include physiological measures; these can be particularly helpful in patients who are pre-verbal or non-verbal such as newborns, young children, patients that may have a developmental challenge, and unconscious patients. However, vital sign changes cannot help you differentiate between pain and other forms of distress such as fear and anxiety. You should always consider the context when interpreting vital signs because they can be affected by the level of consciousness, medications, and sedation. Therefore, your clinical judgement will be based on a comprehensive subjective and objective assessment, along with critical thinking.

	Inspection of the area: Typically, you will inspect the area on the body where a patient indicates they are having pain. Inspection is performed bilaterally in which you compare the left side to the right side. For example, if a patient is having eye pain, you should compare the left eye to the right eye. Inspect for and note any abnormalities such as discolouration (e.g., redness), bruising, swelling, scarring, incisions, masses, deformities, asymmetry, lesions, non-intact skin, and pressure injuries.
	Palpation of the area: After conducting a subjective assessment, you should palpate the area (and related areas) in which the patient is having pain. Palpation is performed bilaterally: compare the left side to the right side. For example, if a patient is having left shoulder pain, you should palpate the right shoulder first and then the painful left shoulder.  You should also observe any signs of pain during palpation, such as a change in respiration (e.g., holding their breath), facial grimacing, withdrawing their body/limb, and guarding.
	Perform auscultation and percussion when a patient is describing chest or abdominal pain. For example, with chest pain, you should auscultate the lungs and the apical pulse and cardiac valves.

Priorities of Care

Some of the main priorities of care related to pain assessment include:

Pain Management Strategies

Pain can be challenging for patients, and understanding how to manage it is crucial. The following section will look at various pain management strategies that are important to providing effective nursing care. Two main strategies will be explored; this includes pharmacological and non-pharmacological therapies. Effective pain management will often use a combination of these strategies.

Pharmacological Therapy

Pharmacological therapy can be very effective in treating pain. Pharmacological therapy is the use of medication to treat a disease, illness, or medical condition. The type of medication depends on the type, duration, and severity of the pain (Ford, 2019). There are three main types of pain medications: opioid analgesics, non-opioid analgesics, and adjuvants. An analgesic is a medication used to relieve pain. When administering pain medications, the nurse must consider the patient’s goals for pain relief and determine if past medications have been effective. The nurse must also consider if the patient is experiencing any side effects that may impact the patient and be aware of contraindications. Patients should be involved and engaged in their pain management plan. Research has shown improved patient outcomes when patients work together with the healthcare team to manage their pain.

Opioid Analgesics

An opioid analgesic is a powerful prescription medication that helps reduce pain by blocking pain signals. Common opioids include codeine, morphine, fentanyl, oxycodone, and tramadol. Different opioids have different amounts of analgesia, ranging from codeine used to treat mild to moderate pain, to morphine used to treat severe pain. Opioids are commonly administered orally or intravenously, but can also be administered rectally, subcutaneously, intramuscularly, or through the skin. The following are some common opioid analgesics.

Opioid Risks

Opioids have a high risk of addiction and overdose, so it is important to consider other forms of pain management before prescribing opioids (National Center for Injury Prevention and Control, 2022). The Centers for Disease Control and Prevention (CDC) recommends avoiding opioids for pain management in patients younger than 18 years old, and avoiding opioids as first-line therapy for chronic pain (Dowell et al., 2022). First-line therapy is medical treatment that is recommended as the best option for the initial treatment of a disease or medical condition.

It is important that patients are informed about the side effects and risks of opioids. Side effects of opioids include the following: Addiction Confusion Constipation Drowsiness Itching Nausea and vomiting Overdose Physical dependence Respiratory depression Tolerance.

Constipation, nausea, and vomiting are common side effects of opioids. Opioids slow peristalsis and cause increased reabsorption of fluid into the large intestine, resulting in slow-moving, hard stools. Nurses should educate patients on preventing constipation with a bowel management program including stool softeners, fluids, a well-balanced diet, and physical activity (as allowed with pain/postsurgical restrictions) to aid in preventing constipation. Because opioids slow gastrointestinal mobility, nausea and vomiting can also occur when taking opioids. Typically, patients will build enough tolerance against nausea and vomiting after taking opioids for a few days. Respiratory depression is one of the most serious potential side effects of opioids. Nurses must closely monitor patients receiving opioids for respiratory depression and administer naloxone to reverse the opioid effects if needed.

As important as pain management is, it is also crucial that healthcare providers are mindful of prescribing opioids to treat pain due to the high risk of addiction and overdose. Addiction is a chronic disease of the brain pursuing reward and/or relief by substance use. Patients who have an addiction have trouble stopping the use of opioids and often struggle with addiction for the rest of their lives. Patients can also struggle with tolerance and physical dependence on opioid misuse. Tolerance is when the body builds up resistance to a medication. Physical dependence is when the patient experiences physical symptoms of withdrawal, such as anxiety, diaphoresis, and muscle cramps when stopping a medication (National Center for Injury Prevention and Control, 2022). Opioids can be very effective in pain management when used appropriately, but healthcare providers must monitor for serious side effects (ANA Center for Ethics and Human Rights, 2018).

Nursing Considerations for Opioids

The nurse should do the following for patients who are taking an opioid:

• Assess the patient’s pain before and after administering an opioid to determine its efficacy in treating the patient’s pain.
• Watch for adverse effects, including sedation, ataxia, slurred speech, and shallow breathing, which could require the use of antidotal therapy or respiratory support.
• With chronic use of opioids, ask about the patient’s bowel movements because constipation is very common with these medications and could be a source of abdominal pain.
• Ensure that naloxone is readily available in the event of opioid toxicity or overdose.
• Provide patient teaching regarding the drug and when to call the healthcare provider.

Patient-Controlled Analgesia

Hospitalised patients with severe pain may receive patient-controlled analgesia (PCA), which allows the patients to safely self-administer opioid medications using a programmed pump. PCA is used to treat acute, chronic, labour, and postoperative pain. A computerised pump contains an opioid analgesic that is connected directly to a patient’s intravenous (IV) line. Doses of medication can be self-administered as needed by the patient by pressing a button. However, the pump is programmed to only allow the administration of medication every set number of minutes with a </ dose of medication every hour. These pump settings, and the design of the system requiring the patient to be alert enough to press the button, are safety measures to prevent overmedication that can cause sedation and respiratory depression. For this reason, no one but the patient should press the button for administration of medication (not even the nurse). In other cases, the PCA pump delivers a small, continuous flow of pain medication intravenously with the patient self-delivering additional medication as needed, according to the limits set on the pump. PCA is useful for patients who have acute pain due to conditions such as trauma, burns, or pancreatitis (Pastino & Lakra, 2023).

The ability of the patient to self-administer pain medication has been shown to increase patient satisfaction and deliver timely pain interventions (Pastino & Lakra, 2023). It also alleviates the burden on both the nurse and the patient of adhering to a strict dosing schedule for PRN analgesics, which may not always provide sufficient pain relief. PCA may be good for patients who are unable to tolerate oral pain medications or for patients who have breakthrough pain and need frequent dosing. The patient can time their medication according to the pain severity for better pain reduction and control.

Nursing Considerations for a PCA

PCA pumps must have certain orders relating to the bolus dose, basal rate, and lockout time. The bolus dose is the dose the patient receives each time they press the button on the PCA pump and is used for breakthrough pain. The basal rate is the continuous rate of the medication that maintains effective pain management. The lockout time is the amount of time after a bolus dose that the pump will not administer medication to the patient, even if they press the button, to prevent overdose. The PCA doses may be dependent on the type of medication, IV site, patient’s weight, current research, and facility guidelines (Pastino & Lakra, 2023). It is important to review your facility’s guidelines when programming PCA dosing.

There are contraindications for PCA. If the patient cannot understand how the PCA works and follow directions, they would not be good candidates for PCA. Allergies, infection, increased intracranial pressure, chronic kidney failure, and bleeding disorders are also contraindications for PCA (Pastino & Lakra, 2023).

Side effects of PCA use are the same as opioids and include constipation, nausea and vomiting, urinary retention, and pruritus (itching). The most serious potential adverse effect of opioids is respiratory depression. Respiratory depression is usually preceded by sedation. The nurse must carefully monitor patients receiving opioids for oversedation, which results in a decreased respiratory rate. Patients at greatest risk are those who have never received an opioid and are receiving their first dose, those receiving an increased dose of opioids, or those taking benzodiazepines or other sedatives concurrently with opioids. If a patient develops opioid-induced respiratory depression, the opioid is reversed with naloxone (Narcan) which immediately reverses all analgesic effects.

Nurses must follow facility guidelines when administering PCA and ensure that the pump is set up correctly. Many facilities have safeguards in place such as a dual nurse sign-off, scanning medications into the electronic medication administration record (eMAR), and guardrails on the pumps to prevent medication errors. To document the amount and frequency of pain medication the patient is receiving, as well as to prevent drug diversion, the settings on the pump are checked at the end of every shift by the nurse as part of the bedside report. The incoming and outgoing nurses double-check and document the pump settings, the amount of medication administered during the previous shift, and the amount of medication left in the syringe.

Non-Opioid Analgesics