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Pain Assessment

1. Definitions

Pain is a complex, subjective experience that encompasses sensory, emotional, and psychological elements. It serves as the body’s warning signal of actual or potential tissue damage. Definitions of pain are important to guide clinical approaches and tailor individualized care.

Acute Pain

Short-term, protective pain that typically resolves with healing. It is usually caused by injury, surgery, or illness and is often sharp or intense in nature.

Chronic Pain

Lasts longer than three to six months. It may persist beyond expected healing and is often associated with conditions like arthritis, neuropathy, or back pain.

Nociceptive Pain

Arises from activation of pain receptors due to tissue injury. It can be somatic (skin, muscles) or visceral (organs).

Neuropathic Pain

Results from damage or dysfunction in the nervous system. Often described as burning, shooting, or electric-like sensations.

2. Assessment

Accurate pain assessment is essential for effective pain management. Tools must be age-appropriate and selected based on developmental level, verbal ability, and condition. This section organizes pain scales by population group for easier reference.

PQRST Pain Assessment

The PQRST method is a structured clinical tool to evaluate pain in a comprehensive manner. Each letter represents a domain that prompts deeper inquiry into the patient’s experience. Use these guiding questions when conducting pain assessments to ensure clarity and completeness.

P – Provocation / Palliation
  • What were you doing when the pain started?
  • What makes the pain better? (e.g., rest, medications, heat, cold)
  • What makes the pain worse? (e.g., movement, pressure, stress)
  • Is the pain constant or does it come and go?
Q – Quality / Quantity
  • Can you describe what the pain feels like? (e.g., sharp, dull, stabbing, burning, throbbing)
  • Is the pain steady or does it fluctuate?
  • How would you describe the intensity or severity?
R – Region / Radiation
  • Can you point to where it hurts?
  • Does the pain stay in one spot or does it spread?
  • Does it radiate to other parts of your body (e.g., back, arm, chest)?
S – Severity
  • On a scale of 0 to 10, how would you rate your pain right now?
  • What is the worst your pain has been?
  • What is the least your pain has been?
  • How much does the pain interfere with your daily activities?
T – Timing
  • When did the pain start?
  • Is the pain worse at a certain time of day or night?
  • Is it associated with meals, movement, or specific triggers?
  • Has it gotten better, worse, or stayed the same since it began?
Neonates & Infants
NIPS (Neonatal Infant Pain Scale)

For premature and full-term newborns. Assesses facial expression, cry, breathing, limb movement, and arousal. Common in NICU.

CRIES

Used for 32 weeks gestation to 6 months postnatal. Includes Crying, oxygen requirement, vital signs, expression, and sleep pattern.

CRIES Pain Scale (32 weeks gestation to 6 months)

The CRIES pain scale is used to assess **postoperative pain in neonates and infants**. It evaluates five key behavioral and physiological indicators: Crying, Requires oxygen, Increased vital signs, Expression, and Sleeplessness.

C – Crying
  • 0: No cry – Quiet, not crying
  • 1: Whimper – Mild moaning, intermittent
  • 2: Vigorous cry – Loud, rising, shrill, continuous. May also include a silent cry if intubated, evidenced by facial movements.
R – Requires Oxygen (for SaO2 < 95%)
  • 0: No oxygen required
  • 1: Oxygen required to keep saturation > 95%
  • 2: High oxygen dependency or unstable O2 levels
I – Increased Vital Signs (HR or BP)
  • 0: No increase in HR or BP
  • 1: Increase < 20% from baseline
  • 2: Increase > 20% from baseline
E – Expression (Facial)
  • 0: Relaxed face – Neutral, calm
  • 1: Grimace – Furrowed brow, tight jaw, clenched mouth
  • 2: Continuous grimace, persistent signs of facial tension
S – Sleeplessness
  • 0: Sleeping peacefully or awake calmly
  • 1: Occasional waking, restlessness
  • 2: Frequently awake, agitated, or inconsolable

Scoring: Each category is rated 0–2. The maximum score is 10, which indicates severe pain.

COMFORT Scale (Non-verbal / Pediatric ICU)

Used for infants, children, and non-verbal patients in critical care. Assesses alertness, calmness, respiratory response, physical movement, muscle tone, and facial tension. Each item is scored 1–5; total score ranges 6–30. Higher scores indicate greater distress or pain.

  • Alertness: Deep sleep → Fully alert
  • Calmness/Agitation: Calm → Panicked
  • Respiratory Response: No response → Coughing/struggling to breathe
  • Physical Movement: None → Constant
  • Muscle Tone: Limp → Rigid
  • Facial Tension: Relaxed → Grimacing

Interpretation:

  • 6–10: Adequate sedation/pain control
  • 11–16: Mild discomfort
  • 17–30: Significant pain or distress
Children
FLACC Scale (2 months – 7 years)

Face, Legs, Activity, Cry, Consolability — scored 0–2 in each, total out of 10. Ideal for preverbal or non-verbal children.

FLACC Scale (2 months – 7 years)
F – Face
  • 0: 😊 No particular expression or smile.
  • 1: 😐 Occasional grimace or frown, withdrawn, disinterested.
  • 2: 😣 Frequent to constant frown, clenched jaw, quivering chin.
L – Legs
  • 0: 🦵 Normal position or relaxed.
  • 1: 😟 Uneasy, restless, tense.
  • 2: 🚶‍♂️ Kicking or legs drawn up.
A – Activity
  • 0: 😌 Lying quietly, normal position, moves easily.
  • 1: 🤸 Squirming, shifting back and forth, tense.
  • 2: 🧍 Arched, rigid, or jerking.
C – Cry
  • 0: 🤫 No crying (awake or asleep).
  • 1: 😢 Moans or whimpers, occasional complaint.
  • 2: 😭 Crying steadily, screams or sobs, frequent complaints.
C – Consolability
  • 0: 🧘 Content, relaxed.
  • 1: 🫂 Reassured by occasional touching, hugging, or being talked to, distractible.
  • 2: 🙅‍♀️ Difficult to console or comfort.
FACES Pain Scale (3+ years)

Patients point to a face that best matches their pain. Simple, expressive, and effective for young children.

😀
0
No Pain
🙂
1–3
Mild
😐
4–6
Moderate
😣
7–8
Severe
😢
9
Very Severe
😭
10
Worst Pain
Oucher Scale (3–12 years)

Combines numerical rating and real-child photos. Includes multicultural variations. Helps with visual/verbal kids.

Adults
Numeric Rating Scale (NRS)

Rate pain from 0–10. Easy and quick for most verbal adults and adolescents.

Numeric Rating Scale (NRS)

Rate your pain from 0 (No pain) to 10 (Worst possible pain):

0
😊
No pain
1
🙂
Mild
2
😐
Uncomfortable
3
😕
Tolerable
4
😟
Annoying
5
😣
Moderate
6
😖
Distracting
7
😫
Intense
8
😭
Severe
9
🤢
Unbearable
10
💀
Worst Pain
Visual Analog Scale (VAS)

Mark pain level on a 10cm line. Useful in research or for precise assessment.

Verbal Descriptor Scale (VDS)

Select terms like “mild,” “moderate,” “severe.” Good for elderly or low-literacy patients.

Non-verbal / Cognitively Impaired
PAINAD (Pain in Advanced Dementia)

Observes breathing, facial expression, body language, vocalization, and consolability. Used in elder/hospice patients.

PAINAD – Pain Assessment in Advanced Dementia

Used for non-verbal, cognitively impaired adults (e.g., advanced dementia). Scores 0–2 in each of 5 categories. Max score = 10. Higher = more severe pain.

Category 0 1 2
💨 Breathing
Independent of vocalization		 Normal Occasional labored breathing, short hyperventilation Noisy, long hyperventilation, Cheyne-Stokes
🔊 Negative Vocalization None Moan/groan, disapproving tone Repeated calling, loud moaning/crying
😐 Facial Expression Smiling or blank Sad, frightened, frowning Facial grimacing
🧍 Body Language Relaxed Tense, pacing, fidgeting Rigid, clenched fists, striking out
🤝 Consolability No need to console Distracted/reassured by touch/voice Unable to console, distract, or reassure

🧮 Interpretation: Total score = 0 to 10. Higher scores = greater pain.

Abbey Pain Scale

Assesses vocalization, facial expression, change in behavior, and physiological signs. Often used in end-of-life care.

3. Diagnostic

Diagnostic approaches to pain involve both objective and subjective evaluations to determine underlying causes and guide appropriate interventions. This may include physical exams, lab work, imaging, and interdisciplinary assessments depending on the nature and complexity of the pain.

Physical Examination

Includes inspecting for swelling, redness, and deformities; palpating tender areas; assessing range of motion; and performing neurological exams to check sensation and reflexes.

Imaging Studies

Includes X-rays, CT scans, and MRIs to detect structural issues such as fractures, arthritis, or nerve compression. These tools help confirm physical sources of pain.

Electrodiagnostics

Includes EMG and nerve conduction studies to evaluate nerve and muscle function, especially useful in diagnosing neuropathic conditions.

4. Implementation

Implementation involves executing a comprehensive pain management plan tailored to the patient’s needs. This can include pharmacologic, non-pharmacologic, and integrative strategies to optimize comfort, function, and quality of life.

Pharmacologic Interventions

Use of analgesics including acetaminophen, NSAIDs, opioids, and adjuvant medications like antidepressants and anticonvulsants. Dosage and timing are crucial.

Non-Pharmacologic Techniques

Includes physical therapy, heat/cold therapy, guided imagery, deep breathing, music therapy, and massage. These techniques can complement or reduce medication needs.

Patient Education & Empowerment

Teaching patients about pain expectations, safe medication use, coping strategies, and when to seek help. Empowering patients promotes shared decision-making and better outcomes.

Welcome to your Pain Assessment

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