Managing Pain Assessment Nursing

---
name: managing-pain-assessment-nursing
language: en
description: Applies pain assessment scales (NRS, Wong-Baker, FLACC, BPS) with intervention documentation and reassessment. Use when assessing pain, selecting pain scales, or documenting pain management.
tags:
  - management
  - nursing
metadata:
  author: casemark
  practice_areas:
    - Nursing
    - Advanced Practice
    - Nurse Practitioner
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Pain Assessment Nursing

## Why This Skill Exists

Pain is designated as a fundamental focus of nursing assessment by the ANA, and effective pain management is a Joint Commission standard (PC.01.02.07). CMS Conditions of Participation require that hospitals address pain management as part of patient care. The Joint Commission revised its pain assessment standards in 2018 to emphasize individualized, multimodal approaches and to require organizations to identify patients at high risk for opioid-related adverse events. HCAHPS pain management domains affect hospital reimbursement under Value-Based Purchasing. Undertreated pain leads to delayed recovery, increased length of stay, and chronic pain development. Overreliance on opioids without appropriate assessment contributes to respiratory depression events, a leading cause of in-hospital mortality. This skill structures pain assessment, intervention selection, reassessment, and documentation per current evidence-based standards.

---

## Checkpoint A — Intake Verification

### Required Patient Information
- [ ] Pain history: chronic pain conditions, prior pain experiences, previous treatments and efficacy
- [ ] Current analgesic regimen with last dose times
- [ ] Opioid tolerance status (opioid-naive vs. opioid-tolerant per FDA definition: ≥ 60 mg oral morphine equivalents/day for ≥ 1 week)
- [ ] Substance use history including alcohol, illicit drugs, and prescription drug misuse
- [ ] Allergies and adverse reactions to analgesics
- [ ] Comorbidities affecting analgesic selection: renal insufficiency, hepatic impairment, respiratory disease, history of GI bleeding, sleep apnea
- [ ] Sedation risk factors: advanced age, obesity, sleep apnea, concurrent CNS depressants

### Scale Selection Prerequisites
- [ ] Patient's developmental age and cognitive status assessed
- [ ] Ability to self-report determined (self-report is the gold standard per IASP)
- [ ] Appropriate scale selected based on patient population

---

## Step 1 — Select the Appropriate Pain Assessment Scale

Match the scale to the patient population:

1. **Numeric Rating Scale (NRS)** — adults and children ≥ 8 years who can self-report; 0 (no pain) to 10 (worst imaginable pain)
2. **Wong-Baker FACES Pain Rating Scale** — children ages 3–8, adults with cognitive impairment or communication barriers; patient points to face that matches their pain
3. **FLACC Scale** (Face, Legs, Activity, Cry, Consolability) — infants and children ages 2 months to 7 years, or non-verbal patients; scored 0–10 by observer
4. **Behavioral Pain Scale (BPS)** — intubated/sedated ICU patients; facial expression, upper limb movement, ventilator compliance; scored 3–12
5. **Critical-Care Pain Observation Tool (CPOT)** — ICU patients unable to self-report; facial expression, body movements, muscle tension, ventilator compliance or vocalization; scored 0–8
6. **PAINAD** (Pain Assessment in Advanced Dementia) — patients with advanced dementia; breathing, negative vocalization, facial expression, body language, consolability; scored 0–10
7. **Abbey Pain Scale** — elderly patients with late-stage dementia in non-acute settings

Document which scale was used and the clinical rationale for selection.

---

## Step 2 — Perform Comprehensive Pain Assessment (PQRSTU)

1. **P — Provocative/Palliative**: What makes the pain worse? What makes it better? Has the patient tried any interventions?
2. **Q — Quality**: How does the patient describe the pain? (sharp, dull, burning, stabbing, throbbing, cramping, aching, pressure)
3. **R — Region/Radiation**: Where is the pain? Does it radiate? Ask patient to point to the exact location
4. **S — Severity**: Rate using the selected scale; document the specific number or score
5. **T — Timing**: When did the pain start? Is it constant or intermittent? What is the temporal pattern?
6. **U — Understanding (impact)**: How does the pain affect function? Sleep, mobility, appetite, mood, ADLs?

Also assess:
- **Pain goal**: What level of pain is acceptable to the patient? (functional pain goal, not necessarily zero)
- **Current analgesic effectiveness**: Is the current regimen achieving the patient's pain goal?
- **Non-pharmacological measures** currently in use or previously tried

---

## Step 3 — Assess for Opioid-Related Risk Factors

Before initiating or continuing opioid therapy, screen for risk:

1. **Sedation scale**: Assess using Pasero Opioid-Induced Sedation Scale (POSS):
   - S = Sleep, easy to arouse (acceptable)
   - 1 = Awake and alert (acceptable)
   - 2 = Slightly drowsy, easily aroused (acceptable; increase monitoring)
   - 3 = Frequently drowsy, arousable, drifts off during conversation (unacceptable; reduce opioid dose, increase monitoring to q1h)
   - 4 = Somnolent, minimal/no response (unacceptable; stop opioid, consider naloxone, call rapid response)
2. **Respiratory monitoring**: Rate, depth, pattern, SpO2; end-tidal CO2 (ETCO2) if available for high-risk patients
3. **Risk stratification**: Screen patients at high risk for opioid-related adverse events: opioid-naive, age > 65, BMI > 30, obstructive sleep apnea, concurrent benzodiazepines or sedatives, renal/hepatic impairment
4. **Naloxone availability**: Ensure naloxone is readily available for opioid-naive patients and high-risk patients per institutional protocol

---

## Step 4 — Implement Multimodal Pain Management

Document interventions in the following categories:

### Pharmacological Interventions
- **Non-opioid analgesics** (first-line per WHO analgesic ladder): acetaminophen, NSAIDs (if not contraindicated), gabapentinoids for neuropathic pain
- **Opioid analgesics**: use lowest effective dose for shortest duration; document morphine milligram equivalents (MME)
- **Adjuvant medications**: muscle relaxants, topical analgesics (lidocaine, capsaicin), nerve blocks, local anesthetics
- **PCA pump**: verify settings (demand dose, lockout interval, continuous rate if ordered, 4-hour limit), perform independent double-check per high-alert medication protocol

### Non-Pharmacological Interventions
- Positioning and repositioning
- Ice/heat application (with skin integrity monitoring)
- Distraction techniques (music, guided imagery, conversation)
- Relaxation and deep breathing exercises
- Massage therapy (if not contraindicated)
- Transcutaneous electrical nerve stimulation (TENS) if ordered
- Cognitive-behavioral techniques
- Spiritual or cultural comfort measures per patient preference

Document which interventions were offered, accepted, and implemented.

---

## Step 5 — Reassess Pain After Intervention

Reassessment is mandatory — an intervention without reassessment is incomplete:

1. **IV/IM medications**: reassess within 15–30 minutes of administration
2. **Oral medications**: reassess within 60 minutes of administration
3. **Non-pharmacological interventions**: reassess within 30 minutes
4. **PCA**: reassess per institutional protocol (typically q1h for first 24 hours, then q2–4h)
5. **Document** using the same scale used for initial assessment:
   - Pre-intervention score
   - Intervention provided with time
   - Post-intervention score with time
   - Whether pain goal was met
6. **Escalate** if pain goal is not met after appropriate time and dose: notify provider for order adjustment; document the escalation

---

## Step 6 — Document the Complete Pain Assessment

1. **Pain scale used** and clinical rationale for scale selection
2. **PQRSTU assessment** findings
3. **Severity score** using the selected scale
4. **Patient's functional pain goal**
5. **Interventions implemented** (pharmacological and non-pharmacological) with times
6. **Reassessment findings** with comparison to pre-intervention score
7. **Sedation level** (POSS score) for patients receiving opioids
8. **Patient response** and satisfaction with pain management
9. **Plan**: ongoing management, anticipated needs, provider communication

---

## Checkpoint B — Pain Management Review

### Shift-Level Review
- [ ] Pain assessed at required intervals (at minimum: on admission, each shift, with each new pain report, before and after interventions, before and after procedures)
- [ ] Every pharmacological intervention has a documented reassessment
- [ ] Sedation monitoring documented for all patients receiving opioids
- [ ] Multimodal approach attempted before opioid dose escalation
- [ ] Patient's functional pain goal documented and addressed
- [ ] Unmet pain goals escalated to provider with documented communication

### Safety Review
- [ ] Opioid-naive patients monitored with increased frequency per institutional protocol
- [ ] High-risk patients have capnography or enhanced monitoring if available
- [ ] Naloxone availability confirmed for all opioid-receiving patients
- [ ] No concurrent benzodiazepine + opioid administration without documented clinical necessity and enhanced monitoring

---

## Quality Audit

- [ ] Pain assessment documented per institutional frequency requirements
- [ ] Appropriate scale selected and consistently used for each patient
- [ ] PQRSTU comprehensive assessment documented on admission and with each new pain complaint
- [ ] Reassessment documented within appropriate timeframe for every intervention
- [ ] Sedation scale (POSS) documented for all opioid-receiving patients
- [ ] Multimodal approach documented — non-pharmacological interventions offered alongside pharmacological
- [ ] Functional pain goal established and used as the outcome benchmark
- [ ] Compliant with Joint Commission PC.01.02.07 pain management standards (2018 revision)
- [ ] HCAHPS pain management domain addressed through patient communication and education
- [ ] Documentation supports safe opioid stewardship per institutional and state requirements

---

## Guidelines

- **Joint Commission PC.01.02.07**: Organizations must assess and manage pain; 2018 revisions emphasize multimodal approaches, opioid risk screening, and realistic expectations
- **CMS CoP**: Pain management must be addressed as part of patient assessment and care planning
- **ANA Position Statement**: Pain management and the role of the nurse — nurses have an ethical obligation to provide pain relief
- **IASP**: Self-report is the gold standard for pain assessment; behavioral observation scales are used when self-report is not possible
- **WHO Analgesic Ladder**: Step 1 (non-opioid ± adjuvant), Step 2 (weak opioid ± non-opioid ± adjuvant), Step 3 (strong opioid ± non-opioid ± adjuvant)
- **Pasero Opioid-Induced Sedation Scale**: Required for monitoring patients receiving opioids; POSS ≥ 3 requires immediate intervention
- **HCAHPS**: Pain management communication domain — did staff do everything they could to help with pain; were new medications explained
- **Scope of practice**: RN independently assesses pain, selects appropriate scale, implements non-pharmacological interventions, administers analgesics per order, evaluates effectiveness, and advocates for order modification; LPN/LVN may collect pain data and implement interventions under RN direction per state Nurse Practice Act
- **Opioid stewardship**: Document morphine milligram equivalents (MME), screen for risk factors, use multimodal first-line approaches, and monitor for adverse events including respiratory depression and sedation