Assessing pain

A complete assessment guides the plan.

PopulationRecommended approach
Adults able to self-reportNumeric rating scale 0–10
Young children (about 3 and older)Faces-based scale
Infants and preverbal childrenBehavioral scale such as FLACC (Face, Legs, Activity, Cry, Consolability)
Adults with advanced dementiaBehavioral scale such as PAINAD
Critically ill, intubated clientsBehavioral scale such as CPOT

Vital sign changes are not reliable indicators of chronic pain; their absence does not mean the client has no pain.

Pain assessmentLocationWhere;radiates?IntensityScale scoreQualitySharp, burning,achingTimingOnset, durationFunctionSleep, walking,mood
Pain assessment. Ask what has helped before and what the client's goal is.

Managing pain

Multimodal plans combine drugs with different mechanisms and non-drug measures.

AssessSelf-reportor behavioralscalePlanGoal withclientInterveneDrug +non-drugReassessAt peakeffectAdjustReport if notcontrolled
Pain management cycle. Give analgesics before pain becomes severe and before painful activities, such as dressing changes.
Non-drug measureNotes
ColdOften used in the first 24–48 hours after injury to reduce swelling
HeatMuscle spasm and chronic pain; avoid over impaired sensation or bleeding
Positioning and splintingSupport the painful area; splint incisions to cough
Distraction, music, guided imagery, relaxationUseful alone for mild pain and with drugs for more severe pain
MassageAvoid over a suspected DVT, open wounds, or fragile skin
TENSElectrical stimulation; not over the chest of clients with pacemakers without approval

Check skin before and after heat or cold, and limit application time to prevent injury.

Myths and special populations

Many NCLEX distractors are pain myths.

MythOlder adults feel less painInfants do not feel painSleeping clients have no painTaking opioids for acute pain causesaddictionStable vital signs mean no painFactOlder adults often underreport painInfants feel and respond to painClients may sleep from exhaustionAddiction is uncommon with short-termuse; tolerance and dependence differChronic pain often has normal vitalsignsvs
Pain myths. Tolerance (needing more drug for the same effect) and physical dependence (withdrawal if stopped) are not the same as addiction (compulsive use despite harm).

Comfort beyond pain

Rest and comfort are also part of Basic Care and Comfort.

  • Promote sleep: keep a routine, reduce noise and light at night, cluster care, limit caffeine late in the day.
  • Assess and treat nausea; offer small meals and mouth care.
  • Address cultural and spiritual preferences about pain expression and treatment.

NGN-style case

Choosing the right assessment tool.

functions Clinical judgment case — the client who cannot say

A client with advanced dementia is moaning, grimacing, and guarding the left hip 2 days after a fall. The client cannot rate pain on a number scale. What should the nurse do?

  1. Recognize cues: moaning, grimacing, guarding; recent fall.
  2. Analyze: probable pain the client cannot self-report.
  3. Use a behavioral pain scale designed for dementia (such as PAINAD) and look for causes (possible fracture).
  4. Give ordered analgesia, reassess with the same scale, and notify the provider about possible injury.

Answer. Assess with a behavioral scale such as PAINAD, treat as ordered, reassess, and report possible hip injury.