Christy Bowen; Bridget Carey; Jessica Palozie; Maren Reinholdt

Learning Objectives

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

Discuss key elements of assessing a patient’s pain
Relate principles of pain assessment to pain reassessment after evaluation

According to the American Pain Society, pain is the fifth vital sign (Department of Veterans Affairs, 2000). Just as blood pressure, heart rate, respirations, and temperature inform the nurse of the patient’s condition, so does pain. Pain assessments should be performed routinely to allow for better pain management by developing a treatment plan that meets the individual needs of the patient.

Performing a Pain Assessment

Perform pain assessments on a regular basis, before and after procedures, during routine checkups, and when a patient reports pain. Prior to administering pain medication, nurses must perform a thorough pain assessment. They must then reassess the pain at least fifteen minutes after administering the medication to evaluate effectiveness. Conducting a pain assessment is a multifactorial process that involves gathering several different sources of information. A thorough pain assessment identifies the patient’s risks for pain, assesses the pain using an approved pain scale, determines the classification of pain (nociceptive, neuropathic, referred, somatic, visceral, phantom), determines if the pain is acute or chronic, and assesses the patient’s previous response to pharmacological interventions and analgesics, noting any adverse reactions. During a pain assessment, the patient should also be assessed for physical, behavioral, and emotional signs of pain, such as confusion, diaphoresis, moaning, decreased activity, irritability, guarding, grimacing, clenched teeth, muscle tension, depression, and insomnia. These cues are important because they may not align with the results obtained by a pain screening tool. By combining several different ways of assessing pain, the nurse can better understand and manage a patient’s pain experience and determine next steps when discrepancies in pain assessments arise.

Cultural Context

Cultural Perspectives of Pain

Culture is directly related to the physical and emotional expression of pain. Some cultures, such as those based in east Asia, place great value on self-discipline and control. Persons with these backgrounds may be more stoic, choosing to bear their pain and withdraw socially rather than express their discomfort. Even when experiencing severe pain, their facial expression may be neutral. Other cultures, such as those with Middle Eastern or Mediterranean roots, may place greater value in the expression of pain; people with these backgrounds may want others around them when they are in pain (Givler et al., 2023). Additionally, there are myths associated with certain cultures an pain. For example, studies have shown that providers are less likely to provide pain medication for Black patients (Sabin, 2020).

Despite these examples, it is important not to generalize about someone’s pain based upon their culture alone. Instead, nurses must understand how a patient’s culture may affect pain and use this information to create an individualized plan to best meet their individual needs.

Mnemonics for Assessment

Nurses often use mnemonics to remember standardized questions for conducting a comprehensive pain assessment. Although there may be a variety of mnemonics in use, three of the most common mnemonics are:

COLDSPA
OLDCARTES
PQRSTU

The letters in each mnemonic stand for important categories of information relevant to a patient’s pain experience. Nurses may ask any number of questions to obtain information for each category. Table 7.2 lists questions that can be used to assess pain using the COLDSPA mnemonic.

COLDSPA	Questions to Ask
C: Character	What does the pain feel like? Does it feel like burning, stabbing, aching, dull, throbbing, etc.?
O: Onset	When did the pain start? What were you doing when the pain started?
L: Location	Where do you feel the pain? Does it move around or radiate elsewhere? Can you point to where it hurts?
D: Duration	How long has the pain lasted? Is the pain constant or does it come and go? If the pain is intermittent, when does it occur?
S: Severity	How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced? How much does it bother you?
P: Pattern	What makes your pain feel better? What makes your pain worse? Does the pain increase with movement, certain positions, activity, or eating?
A: Associated factors	What do you think is causing the pain? What other symptoms occur with the pain? How does the pain affect you?

Table 7.2 COLDSPA Assessment

The OLDCARTES mnemonic consists of similar categories as well as specific prompts related to pain treatment. Table 7.3 lists questions that can be used to assess pain using the OLDCARTES mnemonic.

OLDCARTES	Questions to Ask
O: Onset	When did the pain start? Can you recall any specific incident or event that caused the pain to begin?
L: Location	Where is the pain located? Can you point to where it hurts?
D: Duration	How long has the pain been bothering you? Is the pain continuous, or does it come and go?
C: Character	What does the pain feel like? Does it feel like burning, stabbing, aching, dull, throbbing, etc.?
A: Aggravating factors	What makes the pain worse? Are there any activities, movements, or conditions that make the pain worse?
R: Radiating	Does the pain travel to other parts of your body? Can you describe where the pain spreads to?
T: Treatment	What has been done to make the pain better and has it been helpful?
E: Effect	How does the pain affect your daily activities and quality of life?
S: Severity	On a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain?

Table 7.3 OLDCARTES Assessment

The PQRSTU mnemonic uses fewer letters by combining several categories. Table 7.4 lists questions that can be used to assess pain using the PQRSTU mnemonic.

PQRSTU	Questions to Ask
P: Provocation/Palliation	What makes your pain worse? What makes your pain feel better?
Q: Quality	What does the pain feel like? Note: You can provide suggestions for pain characteristics such as “aching,” “stabbing,” or “burning.”
R: Region/Radiation	Where exactly do you feel the pain? Does it move around or radiate elsewhere? Can you point to where it hurts?
S: Severity	How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?
T: Timing/Treatment	When did the pain start? What were you doing when the pain started? Is the pain constant or does it come and go? If the pain is intermittent, when does it occur? How long does the pain last? Have you taken anything to help relieve the pain?
U: Understanding	What do you think is causing the pain?

Table 7.4 PQRSTU Assessment

Regardless of the pain assessment framework used, it is important to use open-ended questions that allow the patient to describe the pain in their own words. Closed-ended questions result in “yes” or “no” responses and fail to capture a comprehensive description of the pain. It is also important to follow up on the patient’s initial responses by asking clarifying questions and to continue asking questions until you have a clear enough understanding of the pain to develop and implement an individualized pain treatment plan. In doing so, the nurse should collaborate with the patient to establish reasonable pain goals that are fluid over time and reflective of the patient’s current condition.

Pain Is Subjective

Given that pain is invisible and everyone’s body is different, every person’s response to pain will be different. Even with the same stimuli, the perception of pain will vary from person to person and cannot be generalized across persons. For example, some patients may experience severe pain when receiving injections, whereas others may feel no pain at all. Consequently, nurses must consider pain to be whatever the patient says it is. Table 7.5 displays the biological, psychological, and social factors that affect the perception of pain. Nurses must consider these factors when assessing and treating pain.

Category	Factors
Biological	Nociception Brain function Source of pain Illness Medical diagnosis Age Injury, past or present Genetic sensitivity Hormones Inflammation Obesity Cognitive function
Psychological	Mood/affect Fatigue Stress Coping Trauma Sleep Fear Anxiety Developmental stage Meaning of pain Memory Attitude Beliefs Emotional status Expectations
Social	Culture Values Economic status Environment Social support Coping mechanisms Spirituality Ethnicity Education

Table 7.5 Factors Affecting the Perception of Pain

Real RN Stories

Nurse: Kevin, BSN
Years in Practice: Twelve
Clinical Setting: Medical-surgical unit in a rural hospital
Geographic Location: Rural Alabama

The community in which our hospital is located experiences a high rate of homelessness, higher than the average rate in the United States. During the cold winter months, we typically see an increase in persons without housing seeking care in the emergency department (ED).

It was a cold winter night in December when I received a phone call from a nurse in the ED that I was getting a new patient. The patient was a 46-year-old female who was without housing and complaining of back pain. The ED nurse mentioned the patient was a “frequent flier” and a “pain seeker.” The nurse didn’t know why the patient was being admitted other than “to have a warm place to sleep for the night.” The nurse reported that the patient had been given a heat pack but no pain medications. The nurse went on to mention the patient was seen in the ED one week prior, testing was done at that time, and no source of pain was found.

Upon arrival to the unit, the patient was displaying physical signs of pain, such as rocking back and forth, and stated she was in pain. A comprehensive pain assessment was performed, with the patient rating the pain as a 10/10 using the numerical rating scale. I felt uncertain how to proceed in that moment. My assessment told me the patient was in pain, but given the report from the ED nurse and noting the patient’s frequency of ED visits, I began to wonder if the patient really was in pain or if they were just seeking pain medications and a warm place to sleep.

I continued to ask the patient questions to gain a better understanding of the pain. During the assessment, the patient asked to use the restroom. It was at that time that I noted blood in the urine. I asked several follow-up questions and discovered the patient had been feeling a burning sensation with urination. Realizing the cues were signs of a possible kidney stone or kidney infection, I provided the patient with pain medications and notified the provider. The patient ended up having a kidney stone, which was treated. Once the problem was resolved, the patient did not complain of further pain.

Looking back on the situation, I should have recalled that as a nurse, I must be nonjudgmental and recognize that pain is subjective and whatever the patient says it is. The patient was demonstrating physical signs of pain and was sufficiently cognitively aware to provide a pain score. I am glad I decided to ask additional questions to probe the patient a bit further. Had I not done this, I wonder if the patient’s underlying condition would have been identified and treated. All patients have a right to adequate pain control, which starts with believing what the patient says they are experiencing.

Pain Scales

A key factor when assessing pain is to determine the severity of the pain. Because nurses cannot test pain objectively to determine what someone is experiencing, providers use pain scales to gain a concrete understanding of a patient’s pain. These tools may also be used to establish a reasonable pain goal the patient would like to reach. Although nearly all patients would like to have a pain goal of 0, this may not be reasonable for a given individual. For example, someone who just had surgery should expect to have pain for at least several days, and possibly longer.

Nurses have the option of using several standardized pain scales. The most common is the numerical rating scale (NRS). When using this scale, patients are asked to rate their pain between 0 and 10, with 0 being no pain and 10 being the worst pain ever experienced. Typically, a pain score of 0 means no pain, a score of 1 to 3 is mild pain, a score of 4 to 6 is moderate pain, a score of 7 to 9 is severe pain, and a score of 10 is unbearable pain. Severity ratings may vary according to institutional policy. Although simple and easy to use, this pain scale cannot be used for children or others who cannot quantify the severity of pain. As such, these populations require alternative pain scales, such as the FACES scale, FLACC scale, PAINAD scale, behavioral pain scale (BPS), or critical-care pain observation tool (CPOT).

Link to Learning

The University of Florida Health has created a web page that links to many different pain assessment tools as part of their Pain Assessment and Management Initiative.

The FACES scale is a visual tool for assessing pain in children ages 3 and older and others who cannot use a numerical scale. To use the FACES scale, first explain to the patient that each face represents a person who has no pain (or “hurt”), some pain, or a lot of pain: for example, “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 do not have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling. Although simple to perform, the results are not always reliable, and additional assessments may help to determine the severity of the patient’s pain.

The FLACC scale is used to assess pain in children between the ages of 2 months and 7 years, as well as those unable to verbally communicate. This scale has five criteria: face, legs, activity, cry, and consolability. Based on their observations of the patient, the provider assigns each of the five criteria a score of 0, 1, or 2. The provider then adds the scores of each of the five criteria to calculate the overall pain score. The overall total will be between 0 and 10, with 0 being no pain and 10 being severe pain.

The pain assessment in advanced dementia (PAINAD) scale is used to assess pain in patients with Alzheimer disease and advanced dementia. This scale has five criteria: breathing independent of vocalization, negative vocalization, facial expression, body language, and consolability. Similar to the FLACC scale, each of the five criteria in the PAINAD scale are assigned a score of 0, 1, or 2. The provider observes the patient, assigns a score for each criterion, and adds the scores. The total pain score will be between 0 and 10, with 0 being no pain and 10 being severe pain. Like FLACC, the PAINAD scale is simple, valid, and reliable, but it may not always result in the most accurate pain assessment, because it requires the nurse to calculate the score based upon observed patient behaviors rather than the patient’s subjective pain rating.

The behavioral pain scale (BPS) is a tool used to assess and quantify pain in acute sedated ventilated patients in intensive care units (ICUs). This scale relies on the observation of facial expressions, upper limb body movements, and compliance with mechanical ventilation. BPS scores range from 3 (no pain) to 12 (maximum pain).

The critical-care pain observation tool (CPOT) is another standardized assessment tool used in critical-care settings to evaluate pain in critically ill patients who are unable to communicate their pain. The CPOT measures pain through the observation of four behavioral categories: facial expressions, body movements, muscle tension, and compliance with the ventilator (for intubated patients) or verbalization (for extubated patients). CPOT scores range from 0 (no pain) to 8 (maximum pain).

Pain Assessment for Older Adults

In general, persistent pain has been related to depression, anxiety, decreased socialization, sleep disturbances, and slowed mobility. It is therefore crucial that nurses adequately assess and treat pain to maintain the health, well-being, and functional status of older patients, who are more likely to experience pain yet less likely to report being in pain. This is partly because both providers and patients may be inclined to dismiss pain as a normal part of aging. There are also valid concerns about the risks of pain medications leading to opioid dependence, as well as a lack of routine pain assessments that are comprehensive in nature. All these factors have resulted in undertreatment of pain in the older adult population.

A multimodal approach to assessing pain, both by observing physical cues and utilizing tools such as the FACES or PAINAD scales, is essential for treating older adults. If the patient is cognitively impaired or unable to communicate, the nurse should rely heavily on any physical cues noted and treat the patient accordingly.

Clinical Safety and Procedures (QSEN)

Pain Assessment Checklist

Disclaimer: Always follow the institution’s policy for pain assessment.

Special considerations:

Provide developmentally and culturally appropriate education based on the needs of the individual.
Explain to the patient and family that pain control is the patient’s right.
Encourage questions, and answer them as they arise.

Steps	Additional Information
1. Ensure hygiene.	Performing hand hygiene and donning appropriate personal protective equipment reduces the spread of microorganisms.
2. Introduce yourself.	Patients have a right to know who is providing care to them.
3. Verify patient identity.	Verify patient identity using two identifiers, such as name and date of birth.
4. Assess risks for pain.	Consider factors, such as if the patient has recently undergone surgery or an invasive procedure, conditions that are likely to cause pain (e.g., cancer, sickle cell anemia), anxiety, inability to communicate, cognitive impairments, or advanced age.
5. Assess pain using a pain scale.	Use scale appropriate for the patient’s age and cognitive level. Consider age- and cultural-related factors that may prohibit patient from reporting pain.
6. Establish a pain goal with the patient.	Using the same pain scale, ask the patient to set a reasonable pain goal.
7. Determine the classification of pain.	Identify if the pain is nociceptive or neuropathic.
8. Determine whether pain is acute or chronic.	Determine how long the pain has been present. Typically, chronic pain is pain that has lasted longer than six months.
9. Assess response to previous pharmacologic interventions, including analgesics.	How have other medications affected sleeping, eating, vital signs? Has the patient experienced unwanted symptoms with medications in the past, such as itching, nausea, or vomiting?
10. Assess the pain site.	Inspect: Do you notice any swelling, draining, bruising, lumps, or other discolorations? Palpate: Are there painful areas, changes in body temperature, or evidence of altered sensation? Assess range of motion to determine effect on joints. Perform percussion and auscultation to determine potential cause of pain.
11. Assess for physical, behavioral, and emotional signs of pain.	Look for signs, such as moaning, crying, grimacing, clenched teeth, irritability, confusion, diaphoresis, guarding, muscle tension, restlessness, fatigue, insomnia, depression, abnormal gait, decreased activity, or social withdrawal.
12. Assess characteristics of pain.	Use COLDSPA, OLDCARTES, or PQRSTU mnemonics.
13. Assess patient’s preferences in pain management.	Consider cultural factors that may affect pain management. Identify preferences in nonpharmacological supportive therapies.

Reassessment after Intervention

Pain should always be reassessed after implementing an intervention to determine the effectiveness of the intervention in reducing the pain. Typically, pain should be reassessed within one hour of administering oral medications and within fifteen to thirty minutes of administering intravenous medications, depending upon institutional policy. Reassess pain utilizing the same pain scale as the initial pain assessment. If the patient’s pain has not decreased to a level equivalent to their established pain goal, discuss further interventions. These interventions may include additional medications or nonpharmacological modalities, such as heat, ice, music, and repositioning. Intervention (both pharmacological and/or nonpharmacological) and reassessment are required until achieving the patient’s optimal pain goal. Chart all reassessments and interventions in the medical record.

Read the Electronic Health Record

Documenting Pain Assessments

The following is a sample of nursing documentation within an electronical health record (EHR) for pain management. The patient is a 42-year-old male who experienced a stroke. He is NPO because he has swallowing difficulties and has impaired balance, so he cannot ambulate without the assistance of two people. He has expressive aphasia, so the words he says are not the words he means. His last bowel movement was three days ago.

	14:05	14:45	16:10	19:15	20:10	21:25
Vital Signs
Temp	98.2°F					98.4°F
Heart rate	88					78
Resp rate	18					18
BP	138/86					128/78
SpO₂	96 percent					97 percent
Pain Assessment
Pain scale		Numerical	Numerical	Numerical	Numerical
Pain goal		4	4	4
Pain score		7	6	6
Pain description		Achy	Achy	Achy	Achy
Pain location		Stomach	Stomach	Stomach	Stomach
Pain interventions		Medication (see MAR)		Medicated (see MAR)	Repositioned

1.

What information on the EHR concerns you?

2.

What information is documented incorrectly?

7.2 Pain Assessment