Where is your pain? Is it external or internal? Generalized, localized, radiation? Asking the patient with acute pain to point to the painful area with one finger may help to localize the pain. Patients with chronic pain may have difficulty trying to localize their pain.
Duration/Chronology
Onset of the pain? Pain episode last? How often does a pain episode occur? How does the pain develop and progress? Has the pain changed since it first began? If so, how?
Intensity/Severity
Ask the patient to indicate the severity of pain currently experienced using a scale. One example of a scale appears below.
Note that it is important to give patients zero/no pain as an option.
0
1
2
3
4
5
6
7
8
9
10
No pain
Mild
Moderate
Severe
Pain as bad as it can be
It is also helpful to ask how much pain the patient has (on the same scale) when the pain is at its least and at its worst:
Least_________ Worst________
Quality and character
What words would you use to describe your pain?
Aggravating or causal factors
What makes the pain occur or increase in intensity? What makes it worse?
Alleviating or relieving factors
What makes the pain go away or lessen? What makes it better? What methods of relief have you tried in the past? How long were they used? How effective were they?
Pharmacologic and nonpharmacologic methods of relief currently in effect for hospitalized patients should be apparent from the chart. It is important to verify the use of current prescriptions and their effectiveness with the patient. Outpatients may need to be asked to record a medication profile, a thorough and accurate account of all medications they are taking.
Contributing or related factors
Are there any other factors that seem to relate consistently to your pain? Any other symptoms that occur just before the pain begins?
Physiologic responses Vital signs (blood pressure, pulse, respirations)aSkin color Perspiration
Signs of sympathetic stimulation can occur with acute pain but need not be present to verify the presence of pain. Signs of parasympathetic stimulation (decreased blood pressure and pulse, rapid and regular respirations, pupil constriction, nausea and vomiting, and warm, dry skin) may occur, especially with prolonged, severe pain, visceral, or deep pain.
Pupil size Nausea Muscle tension
Observe. Ask the patient whether they are aware of any tight, tense muscles.
Anxiety
Are signs of anxiety evident? May include decreased attention span or ability to follow directions, frequent asking of questions, shifting topics of conversation, avoiding discussion of feelings, acting out, somatizing.
Behavioral responses
Posture, gross motor activities
Does patient rub or support a particular area? Make frequent position changes? Walk, pace, kneel, or assume a rolled-up position? Does patient rest a particular body part? Protect an area from stimulation? Lie quietly? In acute pain, postural and gross motor activities are often altered; in chronic pain, the only signs of change may be postures characteristic of withdrawal.
Facial features
Does the patient have a pinched look? Are there facial grimaces? Knotted brow? Overall taut, anxious appearance? A look of fatigue is more characteristic of chronic pain.
Verbal expressions
Does the patient sigh, moan, scream, cry, or repetitively use the same words?
Affective responses
Anxiety
Do you feel anxious? Are you afraid? If so, how bad are these feelings?
Depression
Do you feel depressed, down, or low? If so, how bad are these feelings? Are your feelings about yourself mostly good or bad? Do you have feelings of failure? Do you see yourself or your illness as a burden to those you care about?
Interactions with others
How does the patient act when they are in pain in the presence of others? How does the patient respond to others when they are not in pain? How do significant others and caregivers respond to the patient when the patient is in pain? When the patient is not in pain?
Degree to which pain interferes with patient's life (use past performance as baseline)
Does the pain interfere with sleep? If so, to what extent? Is fatigue a major factor in the pain experience? Is the conduct of intimate or peer relationships affected by the pain? Is work function affected? Participation in recreational-diversional activities?An activity diary is often helpful—sometimes crucial. One to several weeks of hourly activity recorded by the patient may be necessary. Pain level, food intake, and sleep-rest periods are noted along with activities performed. Separate diaries for inpatient and outpatient episodes may be necessary because hospitalization markedly affects the nature and type of activities performed.
Perception of pain and meaning to patient
Are you worried about your illness? Do you see any connection between your pain and the nature or course of illness? If so, how do you see them as related? Do you find any meaning in your pain? If so, is this beneficial or detrimental to you? Are you struggling to find some meaning for your pain?
Adaptive mechanisms used to cope with pain
What do you usually do to relieve stress? How well do these things work? What techniques do you use at home to help cope with the pain? How well have they worked? Do you use these in the hospital? If not, why not?
Outcomes
Pain management goals? What would you like to be doing right now, this week, this month, if the pain were better controlled? How much would the pain have to decrease (on the 0 to 10 or other scale) for you to begin to accomplish these goals? What is your pain goal (on the 0 to 10 or other scale)?
Keep in mind that a response of “NO pain” may not be an option for some patients. Helping a patient to identify a realistic goal promotes effective pain management.
Factors that may affect expression of pain
Patterned attitudes related to cultural, ethnic and/or social group; family, sex, biological sex, gender and age variables; spirituality; religious beliefs and spirituality; environment and support people; anxiety and other stressors; past pain experience
aIncreases in vital signs may occur briefly in acute pain and may be absent in chronic pain (Pasero & McCaffery, 2011). Reliance on vital signs to indicate the presence of pain should be minimized (Herr et al., 2019). The absence of an increase in vital signs does not mean that pain is not present (Pasero & McCaffery, 2011).
Source: Adapted from Taylor, C., Lynn, P., & Bartlett, J. (2023). Fundamentals of nursing: The art and science of person-centered care (10th ed.). Wolters Kluwer.