Pain Assessment in Nursing: PQRST, Scales & Documentation Examples

Pain assessment is not simply asking:

“What is your pain from 0 to 10?”

A pain score tells you intensity.

It does not tell you:

• where the pain is
• what it feels like
• when it started
• whether it radiates
• what makes it worse
• what makes it better
• how it affects function
• whether it signals an emergency
• whether treatment worked
• whether the treatment caused harm

A safe nursing pain assessment combines the patient’s report, a focused physical assessment, an appropriate pain scale, clinical context, and reassessment after intervention.

What is pain?

The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Two important principles follow:

1. Pain is personal.
2. Inability to communicate does not mean a person is not experiencing pain.

Pain may exist even when:

• vital signs are normal
• imaging is normal
• the patient appears calm
• the patient is laughing
• the patient is sleeping
• the nurse expects less pain
• the patient has a history of substance use
• the patient cannot speak

What is a nursing pain assessment?

A nursing pain assessment is the systematic collection and interpretation of information about a patient’s pain experience.

It may include:

• patient self-report
• PQRST or OLDCARTS questions
• pain intensity scale
• focused physical assessment
• behavioral observations
• vital signs
• medication history
• functional assessment
• psychosocial factors
• treatment goals
• reassessment after intervention

The Joint Commission explains that pain assessment tools generally evaluate at least pain intensity, location, quality, and associated symptoms.

Pain screening vs pain assessment

These terms are related but different.

Pain screening

A screening question determines whether pain is present.

Example:

“Are you having pain right now?”

Pain assessment

If pain is present, the nurse gathers detailed data.

Example:

“Where is the pain?”
“When did it begin?”
“What does it feel like?”
“Does it spread anywhere?”
“What makes it worse?”
“What is the intensity?”
“What symptoms occur with it?”

Why pain assessment matters

An accurate pain assessment helps nurses:

• recognize emergencies
• identify likely pain type
• select appropriate interventions
• evaluate medication effectiveness
• detect opioid-related adverse effects
• communicate changes to providers
• support mobility and recovery
• reduce suffering
• prevent undertreatment
• prevent unnecessary or unsafe treatment
• document clinical judgment

Pain assessment is also central to Next Generation NCLEX clinical judgment.

The nurse must recognize cues, analyze those cues, decide what is urgent, intervene safely, and evaluate the patient’s response.

The nursing pain assessment sequence

Use this sequence when pain is reported or suspected.

1. Assess immediate stability.
2. Ask the patient to describe the pain.
3. Use PQRST.
4. Select the appropriate pain scale.
5. Assess associated symptoms.
6. Perform a focused physical assessment.
7. Review relevant history, medications, and orders.
8. Identify red flags.
9. Intervene within scope and orders.
10. Reassess and document.

Step 1: Check for an emergency first

Before completing a long interview, ask whether the pain could represent immediate danger.

Assess:

• airway
• breathing
• circulation
• level of consciousness
• vital signs
• obvious bleeding
• new neurologic deficits
• severe distress
• rapid deterioration

Examples requiring urgent escalation include:

• chest pain with diaphoresis or dyspnea
• sudden severe headache with neurologic changes
• severe abdominal pain with rigidity
• pain out of proportion to the examination
• sudden limb pain with pallor, numbness, or absent pulse
• severe back pain with new weakness, saddle numbness, or incontinence
• acute eye pain with vision loss
• escalating pain after trauma or surgery
• severe pain with hypotension or altered mental status

PQRST pain assessment

PQRST is a practical framework for assessing pain.

P — Provocation and palliation

Ask what causes, worsens, or relieves the pain.

Questions:

What were you doing when the pain began?
What makes the pain worse?
Does movement make it worse?
Does breathing make it worse?
Does eating affect it?
Does position affect it?
What makes it better?
Have you tried medication, heat, ice, rest, or repositioning?
Did anything help?

Why it matters:

• pain worse with inspiration may suggest pleuritic involvement
• pain triggered by exertion may suggest cardiac ischemia
• pain after eating may suggest GI or biliary causes
• pain relieved by position may help localize a musculoskeletal or visceral problem
• pain relieved by nitroglycerin still requires clinical evaluation

Q — Quality

Ask the patient to describe what the pain feels like.

Possible descriptors:

sharp
dull
aching
burning
stabbing
cramping
pressure
tightness
throbbing
shooting
electric
tingling
tearing
gnawing
heavy
sore

Do not force the patient into your preferred word.

Ask:

“What words would you use to describe it?”

Quality may provide clues:

A descriptor does not establish a diagnosis by itself.

R — Region and radiation

Ask where the pain is and whether it travels.

Questions:

Where is the pain?
Can you point with one finger?
Is it superficial or deep?
Does it move anywhere?
Does it radiate to your arm, jaw, back, shoulder, groin, or leg?
Is it on one side or both?

Document exact location.

Instead of:

Patient has stomach pain.

Write:

Patient reports sharp right lower-quadrant abdominal pain.

A body diagram can help patients identify location and radiation.

S — Severity

Use a validated tool appropriate for the patient’s:

• age
• communication ability
• cognition
• developmental level
• language
• clinical setting
• motor ability
• consciousness

Ask the score now and, when relevant:

What is the pain now?
What was it at its worst?
What is the lowest it has been?
What pain level is acceptable to you?
What activity do you want to be able to do?

Do not assume every patient’s goal is zero pain.

A functional goal may be more meaningful:

“I want to cough and deep-breathe.”
“I want to walk to the bathroom.”
“I want to sleep for four hours.”
“I want to participate in physical therapy.”

T — Timing

Ask when the pain began and its pattern.

Questions:

When did it start?
Was the onset sudden or gradual?
Is it constant or intermittent?
How long does each episode last?
Has it changed?
Is it getting worse?
Does it occur at a certain time?
Did it begin before or after a procedure, meal, injury, or medication?

Timing helps distinguish:

• acute vs chronic pain
• intermittent vs constant pain
• breakthrough pain
• incident pain with activity
• pain that worsens despite treatment

Add the “A” and “F”: associated symptoms and function

PQRST should not be the end of the assessment.

Associated symptoms

Ask about symptoms that occur with the pain.

Examples:

• shortness of breath
• nausea or vomiting
• sweating
• dizziness
• fever
• weakness
• numbness
• tingling
• bowel or bladder changes
• bleeding
• rash
• swelling
• palpitations
• vision changes
• confusion

Functional impact

Ask how pain affects:

• walking
• breathing
• coughing
• sleep
• appetite
• work
• self-care
• mood
• physical therapy
• relationships
• concentration

Example:

Pain is 6/10, but the most important finding is that the patient cannot take a deep breath after abdominal surgery.

PQRST documentation template

P:
Pain worsens with movement and deep inspiration; partially relieved by splinting and rest.

Q:
Sharp and pulling.

R:
Right upper abdominal incision; no radiation.

S:
6/10 at rest and 8/10 with coughing. Patient’s acceptable goal is 3/10 and ability to use incentive spirometer.

T:
Began after surgery yesterday; constant ache with intermittent sharp pain during movement.

OLDCARTS vs PQRST

Some schools and facilities use OLDCARTS.

O — Onset
L — Location
D — Duration
C — Character
A — Aggravating factors
R — Relieving factors
T — Timing
S — Severity

PQRST and OLDCARTS collect similar information.

Use the framework required by your clinical instructor or facility.

Choosing the correct pain scale

The best pain scale is the one the patient can understand and use reliably.

Pain scale selection table

Numeric Rating Scale

The Numeric Rating Scale commonly asks the patient to rate pain from 0 to 10.

0 = no pain
10 = worst pain imaginable

The Veterans Health Administration’s numeric scale asks the patient to rate pain now and may also assess usual, best, or worst pain over a relevant period.

How to ask

“On a scale from 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine, what is your pain right now?”

Strengths

• quick
• familiar
• easy to trend
• useful before and after intervention
• works well for many verbal adults

Limitations

A number alone does not show:

• pain cause
• quality
• functional impact
• emergency symptoms
• treatment safety
• patient goal

Do not label patients by the score

Avoid statements such as:

“They say 10/10 but they are on their phone.”

A person’s behavior does not invalidate their report.

Document observable facts separately:

Patient reports pain 10/10. Patient speaking in full sentences and using phone. No diaphoresis noted. PQRST assessment completed.

Verbal Descriptor Scale

A verbal descriptor scale uses words such as:

no pain
mild
moderate
severe
very severe
worst possible pain

It may be useful for:

• older adults
• patients uncomfortable with numbers
• patients who can communicate verbally but cannot conceptualize a numeric scale

Use the same wording consistently during reassessment.

Wong-Baker FACES Pain Rating Scale

The Wong-Baker FACES scale was originally created with children and is now used with people age 3 and older who can self-report using the faces.

The official instructions emphasize that the faces show how much the person hurts.

They do not show mood.

How to use it

Explain:

“These faces show how much something can hurt. Point to the face that shows how much you hurt right now.”

Do not say:

“Which face shows how sad you are?”

Appropriate use

• child age 3 or older who understands the tool
• adult who prefers a visual self-report tool
• patient with communication needs who can reliably select a face

Common mistake

Do not choose the face for the patient.

The patient self-reports.

FLACC pain scale

FLACC stands for:

Face
Legs
Activity
Cry
Consolability

Each category is scored from 0 to 2 for a total of 0 to 10.

FLACC was developed for behavioral assessment of postoperative pain in young children and has also been adapted for some nonverbal populations.

When to use FLACC

• preverbal child
• young child unable to self-report
• selected nonverbal patients when facility policy supports it
• patient whose developmental status makes self-report unreliable

FLACC categories

Important limitation

Behavior may reflect:

• fear
• hunger
• anxiety
• neurologic impairment
• sensory overload
• fatigue
• pain

Interpret the score in clinical context.

PAINAD pain scale

PAINAD stands for Pain Assessment in Advanced Dementia.

It is an observational tool for patients with advanced dementia who cannot reliably self-report.

The original tool contains five categories and a total score from 0 to 10.

PAINAD categories

Breathing independent of vocalization
Negative vocalization
Facial expression
Body language
Consolability

How to use PAINAD safely

Assess behavior:

• at rest
• during movement
• during care
• before intervention
• after intervention

Also consider:

• infection
• constipation
• urinary retention
• hunger
• fear
• delirium
• positioning
• environmental stress
• baseline behavior reported by family or caregivers

Important PAINAD rule

A PAINAD score is not the patient verbally rating pain.

Document it as an observational score.

Example:

PAINAD 6/10 during repositioning, with grimacing, moaning, rigid posture, and limited consolability.

Do not write:

Patient reports pain 6/10.

The patient did not self-report that number.

CPOT pain assessment

CPOT stands for Critical-Care Pain Observation Tool.

It is used for critically ill adults who cannot self-report, including some mechanically ventilated patients.

CPOT evaluates four behavioral domains:

Facial expression
Body movements
Muscle tension
Compliance with ventilator or vocalization

The total score ranges from 0 to 8.

When CPOT may be used

• mechanically ventilated adult
• sedated adult who cannot self-report
• critically ill nonverbal adult
• before, during, and after potentially painful procedures

CPOT caution

CPOT supports detection and trending of pain-related behavior.

It does not replace assessment of:

• sedation
• delirium
• respiratory status
• hemodynamic instability
• neurologic status
• underlying cause

Pain assessment in children

Children require developmentally appropriate communication.

Pediatric approach

1. Ask the child directly when developmentally able.
2. Use the same scale consistently.
3. Ask the parent or caregiver about baseline behavior.
4. Observe movement, guarding, sleep, feeding, and consolability.
5. Reassess after intervention.

Child-friendly PQRST questions

Show me where it hurts.
What does it feel like?
Does it hurt all the time or only sometimes?
What makes it hurt more?
What helps it feel better?
Which face shows how much it hurts?

Do not assume quiet means comfortable

A frightened or critically ill child may become:

• quiet
• withdrawn
• still
• difficult to console
• sleepy
• less interactive

Pain assessment in older adults

Pain may be underrecognized in older adults because of:

• cognitive impairment
• hearing loss
• language barriers
• fear of addiction
• fear of being a burden
• belief that pain is normal with aging
• atypical presentation
• polypharmacy
• altered metabolism

Older-adult assessment tips

• use hearing aids and glasses
• speak slowly and clearly
• allow time to answer
• use a consistent tool
• assess function
• ask family about baseline behavior
• check for delirium
• monitor medication adverse effects
• assess constipation and falls risk

Pain is not a normal consequence that should simply be accepted because a patient is older.

Pain assessment in nonverbal patients

Use a hierarchy.

1. Attempt self-report using communication support.
2. Look for known pain-producing conditions or procedures.
3. Observe behaviors.
4. Ask family or caregivers about baseline behaviors.
5. Consider an analgesic trial when clinically appropriate and ordered.
6. Reassess behavior and function.

Communication support may include:

• interpreter
• writing board
• picture board
• yes/no signals
• eye-gaze system
• communication device
• hearing aids
• caregiver input

Do not assume intubation means the patient cannot communicate.

Pain assessment with an interpreter

Use a qualified medical interpreter when needed.

Do not rely on:

• a child
• an untrained visitor
• gestures alone
• automatic translation for critical details

Speak to the patient, not the interpreter.

Ask one question at a time.

Confirm understanding.

Types of pain nurses should recognize

Acute pain

Acute pain usually has a recent onset and may be associated with:

• surgery
• injury
• infection
• inflammation
• procedure
• acute illness

The priority is to identify the cause, relieve pain safely, and reassess.

Chronic pain

CDC describes chronic pain as pain lasting more than three months.

Chronic pain assessment should include:

• intensity
• function
• sleep
• mood
• activity goals
• medication benefit
• medication harm
• quality of life
• flare pattern

A chronic pain flare can still represent a new emergency.

Do not automatically attribute new pain to the chronic condition.

Nociceptive pain

Nociceptive pain occurs when tissue injury or inflammation activates pain receptors.

It may be:

• somatic
• visceral

Somatic pain

Often localized.

Examples:

• incision
• fracture
• muscle strain
• pressure injury

Visceral pain

May be diffuse or poorly localized.

Examples:

• bowel obstruction
• biliary pain
• renal colic
• organ inflammation

Neuropathic pain

Neuropathic pain may be described as:

• burning
• shooting
• electric
• tingling
• pins and needles
• numbness with pain

Examples include:

• diabetic neuropathy
• postherpetic neuralgia
• radiculopathy
• nerve injury

Referred pain

Pain may be perceived away from the source.

Examples:

• cardiac pain in the jaw or arm
• diaphragmatic irritation at the shoulder
• gallbladder pain near the right shoulder or back

Referred patterns support assessment but do not establish diagnosis.

Focused physical assessment for pain

Your physical assessment depends on the complaint.

General assessment

Observe:

• posture
• guarding
• facial expression
• mobility
• breathing pattern
• skin color
• diaphoresis
• distress
• level of consciousness

Check relevant vital signs.

Vital signs can support assessment, but normal vital signs do not disprove pain.

Musculoskeletal pain

Assess:

• location
• swelling
• bruising
• deformity
• range of motion
• strength
• sensation
• distal pulses
• capillary refill
• temperature
• mechanism of injury

Abdominal pain

Use the abdominal assessment sequence:

Inspect
Auscultate
Percuss if within role/training
Palpate last

Assess:

• location
• distention
• bowel sounds
• guarding
• rigidity
• nausea/vomiting
• bowel movement
• flatus
• urinary symptoms
• pregnancy possibility where relevant
• surgical history

Chest pain

Immediately assess:

• airway and breathing
• vital signs
• oxygen saturation
• pain location and radiation
• quality
• onset
• associated dyspnea
• diaphoresis
• nausea
• palpitations
• mental status

Follow facility chest-pain or emergency protocol.

Do not delay escalation for prolonged documentation.

Headache

Assess:

• sudden vs gradual onset
• “worst headache”
• neurologic deficits
• vision changes
• fever
• neck stiffness
• trauma
• anticoagulants
• pregnancy/postpartum status
• blood pressure
• prior headache pattern

Limb pain

Assess neurovascular status:

Pain
Pallor
Pulse
Paresthesia
Paralysis
Poikilothermia/temperature change

Severe pain out of proportion, pain with passive stretch, tense swelling, numbness, or reduced perfusion requires urgent escalation.

Pain red flags nurses should not miss

Chest and cardiopulmonary red flags

• pressure, squeezing, or heaviness
• pain radiating to jaw, arm, shoulder, or back
• dyspnea
• diaphoresis
• hypotension
• syncope
• new arrhythmia
• cyanosis

Neurologic red flags

• sudden severe headache
• new weakness
• facial droop
• speech change
• seizure
• confusion
• decreased level of consciousness
• neck stiffness with fever

Abdominal red flags

• rigid abdomen
• rebound or severe guarding
• pulsatile mass
• hematemesis
• melena
• hypotension
• persistent vomiting
• severe pain out of proportion

Musculoskeletal and vascular red flags

• absent or diminished pulse
• pallor
• cool limb
• numbness
• paralysis
• severe swelling
• pain with passive movement
• rapidly escalating postoperative pain

Spine red flags

• saddle anesthesia
• new urinary retention or incontinence
• new bowel incontinence
• bilateral leg weakness
• fever with spinal pain
• trauma with neurologic change

Pain assessment before giving an analgesic

Before administering pain medication, assess:

Current pain score/tool:
PQRST findings:
Functional impact:
Vital signs:
Level of consciousness:
Respiratory rate and quality:
Oxygen saturation when indicated:
Sedation level:
Allergies:
Last analgesic:
Total recent opioid dose:
Renal/hepatic concerns:
Fall risk:
Concurrent sedatives:
Current order and route:

Opioid-specific safety assessment

For opioid administration, pay close attention to:

• respiratory rate
• respiratory depth
• sedation
• level of consciousness
• oxygen needs
• sleep apnea
• opioid tolerance
• age
• renal/hepatic impairment
• benzodiazepines or other sedatives
• recent opioid doses

Follow facility policy, medication parameters, and provider orders.

Do not give medication solely because a clock says it is available.

Assess first.

Reassessing pain after intervention

Pain reassessment asks two questions:

1. Did the intervention help?
2. Did the intervention cause harm?

What to reassess

Document:

• pain intensity using the same tool
• location and quality if changed
• functional improvement
• level of consciousness
• sedation
• respiratory status
• adverse effects
• patient satisfaction or goal
• need for escalation

Reassessment timing

Follow:

• facility policy
• medication route
• expected onset
• drug characteristics
• patient condition
• urgency of symptoms

Common clinical practice may reassess sooner after IV medication than after oral medication, but there is no single minute interval appropriate for every drug, route, patient, or setting.

Do not copy a universal “15/30/60-minute rule” without checking local policy.

Nonpharmacologic reassessment

Reassess after:

• repositioning
• ice or heat
• splinting
• relaxation
• distraction
• elevation
• environmental changes
• massage if appropriate
• physical support

Functional pain goals

A pain score of zero may be unrealistic or unnecessary.

Ask what the patient needs to do safely.

Examples:

Ambulate 50 feet.
Participate in physical therapy.
Cough and deep-breathe.
Sleep for four hours.
Eat a meal.
Complete wound care.
Perform ADLs.

Document both intensity and function.

Example:

Pain decreased from 7/10 to 4/10. Patient able to ambulate to bathroom with walker and standby assistance.

Nonpharmacologic pain interventions

Depending on the condition and order/policy, options may include:

• repositioning
• splinting incision
• ice
• heat
• elevation
• rest
• reduced noise/light
• relaxation breathing
• guided imagery
• music
• distraction
• massage
• physical therapy techniques
• TENS
• emotional support

Do not apply heat or ice automatically.

Check:

• diagnosis
• skin integrity
• circulation
• sensation
• procedure restrictions
• duration
• provider order/policy

Pain, bias, and respectful care

Pain assessment can be affected by bias.

Patients may be undertreated because of assumptions about:

• race
• ethnicity
• age
• sex
• disability
• mental illness
• substance use history
• socioeconomic status
• communication style
• frequency of hospital visits

Avoid labels such as:

drug seeking
dramatic
attention seeking
manipulative
exaggerating

Document objective findings.

Instead of:

Patient is drug seeking.

Write:

Patient reports lumbar pain 9/10 and requests IV hydromorphone by name. Last ordered dose administered at 1000; next PRN dose available at 1400. Nonpharmacologic options offered. Provider notified of persistent pain.

A history of opioid use disorder does not eliminate the need for pain assessment and management.

Nursing pain documentation

High-quality charting tells the clinical story.

What to document

Pain presence:
Scale/tool used:
Score:
Location:
Quality:
Radiation:
Onset and timing:
Aggravating/relieving factors:
Associated symptoms:
Focused assessment findings:
Functional impact:
Patient goal:
Intervention:
Medication dose/route/time:
Nonpharmacologic care:
Provider notification:
Reassessment:
Adverse effects:
Next plan:

Documentation rule

Chart what the patient reported and what you observed.

Keep them distinct.

Example:

Patient reports 8/10 pain.

is different from:

Patient grimacing and guarding abdomen.

Both may be documented.

PQRST nursing documentation examples

Example 1: Postoperative incisional pain

Patient reports constant aching pain at midline abdominal incision, 6/10 at rest and 8/10 with coughing. Pain began after surgery yesterday and does not radiate. Worsens with movement and deep breathing; improves with splinting. Incision clean, dry, and approximated. Abdomen soft with expected incisional tenderness. Respirations 18/min, regular and unlabored. Patient’s goal is pain 3/10 and ability to use incentive spirometer. Oxycodone 5 mg PO administered per PRN order at 0910; repositioned and instructed to splint incision.

Example 2: Reassessment after oral analgesic

Pain reassessed at 1010 using numeric scale. Patient reports pain decreased from 6/10 to 3/10 at rest and is able to cough, deep-breathe, and use incentive spirometer. Respirations 16/min, regular; patient alert and easily arousable. Denies nausea, dizziness, or itching. Goal met. Will continue current plan.

Example 3: Acute chest pain

At 1420, patient reported sudden substernal pressure rated 8/10 radiating to left arm, with shortness of breath and diaphoresis. BP 96/58, HR 112, RR 24, SpO2 92% on room air. Patient pale and anxious. Rapid response activated per protocol; patient placed on continuous monitoring and emergency measures initiated per orders/protocol. Provider notified at 1422.

Example 4: Chronic neuropathic pain

Patient reports chronic burning and shooting pain from lower back into left posterior leg, 5/10 now and 8/10 at worst. Pain worsens with prolonged standing and improves with prescribed medication and side-lying position. Reports numbness in left foot unchanged from baseline. Strength 5/5 bilaterally; ambulates with cane. Current goal is to sleep at least 5 hours and walk to dining room. No new bowel/bladder symptoms or saddle anesthesia.

Example 5: Nonverbal patient with advanced dementia

Patient unable to provide reliable self-report. PAINAD score 6/10 during transfer, with labored vocalization, facial grimacing, rigid posture, and limited consolability. Right hip protected during movement. No visible deformity. Acetaminophen administered per order and patient repositioned with support. Family reports grimacing and guarding are not baseline.

Example 6: PAINAD reassessment

PAINAD reassessed 60 minutes after oral acetaminophen and repositioning. Score decreased from 6/10 to 2/10. Patient resting with relaxed facial expression, no moaning, and improved tolerance of turning. No adverse effects observed.

Example 7: Pediatric FLACC assessment

Child nonverbal after procedure. FLACC 7/10: frequent grimace, legs drawn up, tense activity, crying, and difficult to console. Parent present and reports behavior is consistent with pain. Analgesic administered per weight-based order; comfort positioning and distraction provided.

Example 8: CPOT assessment in an intubated patient

Patient intubated and unable to self-report. CPOT 5/8 during turning, with grimacing, protective movement, increased muscle tension, and ventilator dyssynchrony. Hemodynamics stable. Analgesic administered per ICU protocol; turning paused and resumed after comfort measures.

Example 9: Inadequate pain relief

Pain reassessed after intervention. Patient reports persistent right flank pain 8/10, unchanged from premedication score. Continues to guard right side and reports nausea. BP 148/86, HR 104, RR 20, SpO2 98% on room air. Provider notified of uncontrolled pain and associated nausea; awaiting additional orders.

Example 10: Opioid safety concern

Before scheduled reassessment, patient difficult to arouse, with respiratory rate 8/min and shallow respirations after IV opioid administration. SpO2 89% on room air. Opioids held; emergency response and provider notified per policy. Airway support and ordered reversal measures initiated. Continuous monitoring maintained.

What not to chart

Avoid vague charting:

Patient doing better.
Pain okay.
Med worked.
Patient looks comfortable.
No complaints.
Patient exaggerating.
Drug seeking.

Use measurable language:

Pain decreased from 8/10 to 4/10.
Patient able to transfer to chair.
FLACC decreased from 6 to 2.
Respirations 16/min and unlabored.
Patient denies dizziness or nausea.

SBAR for uncontrolled pain

Situation

“Dr. Lee, this is Michelle, RN on 5 South. I am calling about Ms. Carter in Room 518, who has worsening postoperative abdominal pain despite the ordered analgesic.”

Background

“She is postoperative day one after laparoscopic colectomy. Oxycodone 5 mg PO was administered at 1300.”

Assessment

“Pain remains 8/10 at 1400 and is now more diffuse. The abdomen is increasingly distended with guarding. HR is 108, BP 102/64, temp 100.6°F, and she reports nausea. Incisions remain dry.”

Recommendation

“I need you to evaluate the patient now. Would you like additional labs, imaging, antiemetic treatment, or a change in analgesia? I am concerned the pain pattern has changed.”

Pain assessment and NGN clinical judgment

Pain questions on the NCLEX are not only about administering analgesics.

They test clinical judgment.

Recognize cues

Identify:

• pain location
• quality
• onset
• severity
• radiation
• vital signs
• associated symptoms
• behavior
• medication history
• new vs baseline findings

Analyze cues

Ask:

Does this fit expected postoperative pain?
Is the pain changing?
Could this be ischemia?
Could this be infection?
Could this be compartment syndrome?
Could treatment be causing respiratory depression?

Prioritize hypotheses

The most severe pain score is not always the first priority.

Example:

• Patient A: chronic back pain 9/10, stable and unchanged
• Patient B: new chest pressure 5/10 with diaphoresis

Patient B is higher priority.

Generate solutions

Possible safe actions:

• focused assessment
• repositioning
• emergency response
• analgesic per order
• monitoring
• oxygen when indicated and ordered/protocol-driven
• provider notification
• nonpharmacologic intervention

Take action

Intervene based on urgency, orders, scope, and policy.

Evaluate outcomes

Reassess:

• pain
• function
• physiology
• adverse effects
• need for escalation

Delegation and pain assessment

The RN retains responsibility for nursing assessment, clinical judgment, care planning, and evaluation.

A UAP may:

• report that a patient appears uncomfortable
• obtain routine vital signs
• assist with repositioning
• report observed behavior
• support comfort measures within training

A UAP should not independently:

• perform the nursing pain assessment
• interpret pain findings
• decide whether pain is expected
• evaluate medication effectiveness
• change the plan of care

An LPN/LVN may collect pain data and provide care within state law, facility policy, patient stability, and supervision requirements.

Scope varies.

Follow the nurse practice act and facility policy.

Common pain-assessment mistakes

Mistake 1: Recording only a number

Fix:

Add location, quality, timing, function, and associated symptoms.

Mistake 2: Assuming normal vital signs mean no pain

Fix:

Use patient self-report and clinical assessment.

Mistake 3: Using an observational scale when the patient can self-report

Fix:

Ask the patient directly first.

Mistake 4: Documenting PAINAD or FLACC as “patient reports”

Fix:

State that it is an observational score.

Mistake 5: Failing to reassess

Fix:

Reassess effect and adverse effects within policy and expected onset.

Mistake 6: Treating the score instead of the patient

Fix:

Assess function, cause, risk, and clinical context.

Mistake 7: Ignoring a changed pain pattern

Fix:

New location, quality, severity, or associated symptoms require reassessment and possible escalation.

Mistake 8: Labeling the patient

Fix:

Use neutral, objective documentation.

Pain assessment checklist

Immediate stability:
Airway:
Breathing:
Circulation:
Vital signs:
Mental status:

PQRST:
Provocation/palliation:
Quality:
Region/radiation:
Severity/tool:
Timing:

Associated symptoms:
Functional impact:
Patient goal:
Relevant history:
Current medications:
Last analgesic:
Allergies:
Focused assessment:
Red flags:
Intervention:
Provider notification:
Reassessment time:
Reassessment findings:
Adverse effects:
Next plan:

Frequently asked questions about pain assessment in nursing

What does PQRST stand for in pain assessment?

PQRST stands for Provocation/Palliation, Quality, Region/Radiation, Severity, and Timing.

What is the best pain scale for adults?

The 0–10 Numeric Rating Scale works well for many alert adults who understand numbers. The best scale depends on cognition, communication, language, and patient preference.

Is pain always whatever the patient says it is?

The patient’s self-report is central when the patient can communicate reliably. The nurse must also assess clinical context, function, associated symptoms, safety risks, and treatment response.

Can a patient have severe pain with normal vital signs?

Yes. Normal heart rate or blood pressure does not rule out severe pain. Vital signs should not replace self-report.

What is the difference between pain screening and pain assessment?

Pain screening determines whether pain is present. Pain assessment gathers detailed information about intensity, location, quality, timing, associated symptoms, function, and response to treatment.

What pain scale is used for children?

Children who can self-report may use an age-appropriate numeric or faces scale. Wong-Baker FACES is used with people age 3 and older who understand the tool. FLACC may be used for preverbal or nonverbal children.

What is the FLACC pain scale?

FLACC is an observational behavioral tool assessing Face, Legs, Activity, Cry, and Consolability. Each category is scored 0–2 for a total of 0–10.

What is the PAINAD scale?

PAINAD is an observational tool for pain-related behaviors in people with advanced dementia who cannot reliably self-report. It assesses breathing, vocalization, facial expression, body language, and consolability.

What is CPOT?

CPOT is the Critical-Care Pain Observation Tool. It assesses pain-related behaviors in critically ill adults unable to self-report, including some mechanically ventilated patients.

Can I document a PAINAD score as the patient’s reported pain?

No. PAINAD is observational. Document that the patient could not self-report and that the PAINAD score was based on observed behaviors.

When should pain be reassessed after medication?

Reassessment timing depends on medication route, expected onset, patient condition, and facility policy. Reassess sooner when the patient is unstable or when adverse effects are possible.

What should be assessed after an opioid?

Reassess pain, function, level of consciousness, sedation, respiratory rate and quality, oxygenation when indicated, and adverse effects such as nausea, itching, dizziness, or hypotension.

What is an acceptable pain score?

The acceptable score is individualized. For many patients, a functional goal—such as walking, sleeping, coughing, or participating in therapy—is more meaningful than reaching zero pain.

What pain findings require immediate escalation?

New chest pressure, sudden severe headache, rigid abdomen, severe pain out of proportion, neurovascular compromise, new neurologic deficits, or pain with hemodynamic instability require urgent evaluation.

Can pain assessment be delegated to a CNA?

The CNA/UAP can observe, obtain routine data, and report concerns, but the nursing assessment, interpretation, and evaluation remain with the licensed nurse according to scope and policy.

What should I document when pain medicine does not work?

Document the pre-intervention findings, medication and time, reassessment score, unchanged or worsening symptoms, focused assessment, adverse effects, provider notification, and next plan.

How does pain assessment connect to NGN?

Pain assessment helps the nurse recognize cues, analyze whether pain is expected or dangerous, prioritize hypotheses, choose safe interventions, and evaluate outcomes.

Is chronic pain defined by a certain duration?

CDC describes chronic pain as pain lasting more than three months. Chronic pain still requires assessment for changes, function, treatment benefit, and treatment risks.

Should nurses use the term “drug seeking”?

Avoid stigmatizing labels. Document objective behavior, the patient’s request, pain findings, medications already administered, and actions taken.

Final thoughts

A pain score is one data point.

A strong pain assessment tells the full clinical story:

What hurts?
Where?
What does it feel like?
When did it start?
What makes it better or worse?
What symptoms occur with it?
What can the patient no longer do?
Could this be an emergency?
Did the treatment help?
Did the treatment cause harm?

Use PQRST.

Choose the right scale.

Believe the patient’s report while applying clinical judgment.

Assess function and safety.

Reassess after intervention.

Document clearly.

That is how pain assessment becomes safe nursing care rather than a box checked in the electronic record.