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No pain, no gain. Pain Assessment in Nursing

No pain, no gain. Pain Assessment in Nursing

There’s no way around it; the majority of hospital patients are there because they hurt. Maybe that pain brought them to the ER to start with, or perhaps they had a procedure or even a baby, but assessing pain is undoubtedly on your list of things to do every day.

Deep inside, most nurses know many of their patients are not capable of answering the question, “What’s your pain on a scale of 0-10?” Honestly, what does that even mean? Sure, you are equating pain with a number, which tells you what tricks to pull from your bag, but since everyone views pain differently, how accurate is that pain score?

Pain is subjective, but scoring pain shouldn’t be. 

You’ve probably used a mixture of the most common scales, including the visual analog scale (VAS), which lets the user draw a line to a number between 0-10 on a number line, and the numeric rating scale, which is the familiar 0-10 question. Both of these are validated methods to obtain accurate pain assessment. The key here is to actually train the patient on the scale. Adults with no cognitive difficulties are more reliable in their answers when they understand the scope of the scale. We demonstrate this by saying 0 is no pain, and 10 is the worst pain you can imagine. 

Still, grandma will often tell you her fractured hip is at a 3, while the healthy 30-year-old in ER will tell you their tooth pain is a 10 (why is dental pain so bad?). Apparently, the “worse pain you can imagine” is happening right now, in front of you, which may be contrary to the patient’s behavior. 

Variability often indicates a lack of understanding of the scale. Try relating actual injuries. For a woman with children, you could say 0 is no pain, 5 is a bad stomach ache, and 10 is labor. You could also suggest pain reactions like 3 is a dull headache, 8 means you are doubled over, and 10 means you are about to pass out. Find something that relates to the patient; remember, it’s subjective.

No matter how well you explain the scale, some patients will still score their pain higher than you think is appropriate. That’s fine. Pain is what the patient says it is. You should be more worried about the patients who look like they hurt but rate their pain low on the scale. 

Pain scales aren’t perfect.

Sometimes the scale doesn’t work. As we get older, our pain receptors (thankfully) don’t work as well. Some of pain is perception. Many older people under-report pain under the assumption that pain is normal for their age or feel as though they are a burden to healthcare providers. 

Some of your patients just can’t figure out the scale. 0-10 is easy, but it isn’t always the most effective. That matters because pain that isn’t treated effectively can worsen the patient’s condition and even cause long-term effects like depression. In neonates, long-term pain has even been shown to causes changes in neurological pathways for life!

There’s a pain scale for that!

For older adults, adults with cognitive difficulties, or non-verbal patients, a more comprehensive look at pain assessment may give nurses a better idea of what pain control is needed. Scales like the PAINAD or Abbey measure things like breathing rate, negative vocalizations, facial expressions, and body language, as well as consolability to measure pain.

The same scales may also be more effective for young children or infants who can’t communicate pain. The smiley faces in the Wong-Baker Scale may be a good surface indicator of pain. Still, the young child who is devastated at needing some stitches may rate her pain on the saddest smiley face, even though her breathing is normal and she is easily distracted. 

Patients who are sedated may benefit from the behavioral pain scale or the nonverbal pain scale. Both take into account sedation by using compliance with ventilation as an indicator. 

You may have to abide by the doctor’s orders for pain management, but you can use your own nursing judgment when it comes to needing a more advanced pain scale. Your electronic health record likely already has many of the standard options. Often with the benefit of instructions within the tool. If you don’t see a more comprehensive tool, talk to your manager or educator. 

Pain assessment is a vital part of the patient’s care, but it doesn’t help much if it isn’t accurate. Choose the right scale for your situation, and you can be sure your patient’s pain is managed successfully. Just remember to document which scale you used!

Amanda Ernst, DNP, RN, CEN

Amanda Ernst, DNP, RN, CEN


Amanda is an ER nurse with 10 years of healthcare experience. She currently works as a nurse educator and as an adjunct professor for several schools. She also works as a freelance healthcare writer in her spare time. Amanda thinks the greatest thing about nursing is the endless possibilities and opportunities to learn. What have you learned today?


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