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Fundamentals · chapter 30 · Pain Assessment

Pain Assessment

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

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Key points

  1. Multidimensional pain assessment

    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.

  2. Baseline pain data

    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.

  3. Subjective pain questions

    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.

  4. Open-ended questions

    Asking the patient open-ended questions allows them to elaborate on their pain and helps the nurse fully understand the patient’s concerns.

  5. Pain scales selection

    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.

  6. Numeric scale limitations

    Factors such as age, native language, literacy level, and cognitive ability may prohibit patients from understanding the numeric rating scale (Zambon, 2020).

  7. Accept patient rating

    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).

  8. Need additional questions

    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.

  9. Nonverbal pain indicators

    An objective pain assessment includes measuring vital signs, physical assessment, and observing for nonverbal indicators of pain, such as grimacing or moaning.

  10. Self-report barriers

    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.

  11. Assessment before interventions

    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.

  12. Functional impact assessment

    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.

  13. Vital signs context

    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).

  14. Pain documentation timing

    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).

Terms to know

subjective data
Information obtained from the patient and/or family members and offers important cues from their perspective is called subjective data.
comfort-function goal
The comfort-function goal is an individualized patient goal identifying their acceptable pain tolerance while maintaining their daily functions.
Wong-Baker FACES Pain Rating Scale
The Wong-Baker FACES Pain Rating Scale is a visual tool used to evaluate pain severity.
McCaffrey Initial Pain Assessment Tool
The McCaffrey Initial Pain Assessment Tool is another assessment tool that helps patients express their pain.
objective data
Objective data include things that the nurse can measure, such as vital signs and patient behavior.
Affect
Affect refers to the outward display of one’s emotional state.

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

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Every question here, with the answer

  1. A patient with chronic pain rates the pain as 8 out of 10 while calmly eating lunch with family. What is the nurse’s best response?

    1. Document that the pain is mild because the patient appears calm.
    2. Accept the patient’s rating and continue a comprehensive pain assessment.
    3. Use vital signs instead of the patient’s report to determine pain severity.
    4. Reassess only after the patient shows grimacing or crying.

    Answer: Accept the patient’s rating and continue a comprehensive pain assessment.

    Pain is subjective, so the patient’s stated pain rating should be accepted even if behavior appears calm. Behavioral cues are only one part of a comprehensive pain assessment and may not match the subjective report, especially with chronic pain.

  2. A patient is unable to self-report pain after sedation. Which actions should the nurse include when collecting objective pain assessment data? Select all that apply.

    1. Ask the patient to rate pain using a 0 to 10 numeric scale.
    2. Rely only on whether the patient appears calm.
    3. Perform a physical assessment.
    4. Observe for nonverbal indicators such as grimacing or moaning.
    5. Measure vital signs.

    Answer: Perform a physical assessment., Observe for nonverbal indicators such as grimacing or moaning., Measure vital signs.

    For a patient who cannot self-report, objective assessment becomes especially important. The nurse should measure vital signs, perform a physical assessment, and observe nonverbal indicators rather than relying only on appearance or a tool the patient cannot use.

  3. A patient does not understand the numeric rating scale because of language and cognitive barriers. Which pain assessment tool is most appropriate for the nurse to try next?

    1. Document that the patient has no pain because they cannot use the numeric scale.
    2. Use the Wong-Baker FACES Pain Rating Scale.
    3. Ask the nurse to choose a pain score based on the patient’s diagnosis.
    4. Continue repeating the 0 to 10 numeric scale until the patient answers.

    Answer: Use the Wong-Baker FACES Pain Rating Scale.

    If the patient cannot understand the numeric rating scale, the nurse should use a different tool. The Wong-Baker FACES scale is a visual tool that may be easier for patients with different native languages or cognitive delays.

  4. The nurse is documenting a pain assessment for a patient with right shoulder pain. Which entries are appropriate to include? Select all that apply.

    1. Patient is crying and grimacing.
    2. Patient states heat relieves the pain for short periods of time.
    3. Patient reports pain is 7 out of 10 using the numeric rating scale.
    4. Right shoulder has decreased range of motion compared with the left shoulder.
    5. Patient is probably exaggerating because the shoulder looks normal.

    Answer: Patient is crying and grimacing., Patient states heat relieves the pain for short periods of time., Patient reports pain is 7 out of 10 using the numeric rating scale., Right shoulder has decreased range of motion compared with the left shoulder.

    Pain documentation should include subjective data, the pain score and scale used, follow-up information, and observable behaviors or physical findings. Judgmental statements such as saying the patient is exaggerating are not appropriate assessment documentation.

  5. A patient is hunched over, guarding the stomach, and reports nausea and lack of appetite. What should the nurse do first?

    1. Perform a comprehensive pain assessment as the initial intervention.
    2. Document that objective signs of pain are absent.
    3. Assume the symptoms are unrelated to pain because the patient did not request pain medication.
    4. Wait to assess pain until after other interventions are completed.

    Answer: Perform a comprehensive pain assessment as the initial intervention.

    Guarding, nausea, and lack of appetite may be physical signs of pain. The nurse should complete a comprehensive pain assessment before interventions to help determine whether findings are related to pain or another cause.

  6. The nurse is collecting subjective data using the PQRSTU mnemonic. Which questions are appropriate? Select all that apply.

    1. Where exactly do you feel the pain? Does it radiate?
    2. What makes your pain feel worse or better?
    3. What do you think is causing the pain?
    4. Do your vital signs look normal when you are in pain?
    5. How would you rate your pain on scale of 0 to 10?

    Answer: Where exactly do you feel the pain? Does it radiate?, What makes your pain feel worse or better?, What do you think is causing the pain?, How would you rate your pain on scale of 0 to 10?

    PQRSTU questions focus on the patient’s subjective description of provocation or palliation, region, severity, timing or treatment, quality, and understanding. Asking about vital signs is not a PQRSTU subjective pain question and belongs to objective assessment.

Where every quote comes from

Section 30.4 Pain Assessment of Fundamentals of Nursing by Christy Bowen, Lindsay Draper, Heather Moore, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.