Ask the client: “Do you have pain now?” “Have you had pain in the recent past?”

If “yes” to either question, the following data are obtained:

• Pain intensity (use a scale appropriate for the client population)
• Location (ask client to mark on diagram or point to the site)
• Quality, patterns of radiation, character (use client’s own words)
• Onset, duration, variations, and patterns
• Alleviating and aggravating factors
• Present pain management regimen and effectiveness
• Pain management history (medication history, barriers to reporting pain and using analgesics, manner of expressing pain)
• Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration)
• Client’s pain goal (pain intensity and goals related to function, activities, quality of life)
• Physical examination/observation of site(s) of pain

Source: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL, 1999.

(www.jcaho.org)