Understanding Pain Assessment Tools

  1. Nurses need to be savvy when it comes to assessing pain. There are several different pain tools you can use. This article explores pain tools and other aspects of pain to consider when performing pain assessments.

    Understanding Pain Assessment Tools

    Let's talk about pain assessments. Knowing how to assess pain is the first step in effectively treating it. Pain assessments are at the core of good nursing care. All hospitals and other nursing facilities have policies and procedures for pain assessment and management.

    It's not just your hospital or other facilities that believes patients have the right to pain control. The Joint Commission implemented new and revised standards for pain assessment and management in January of this year. The new standards require established policies and procedures that address comprehensive clinical assessment of pain, treatment or referral for treatment and reassessment for patients who report having pain.

    Changes made by accrediting bodies like The Joint Commission remind us that pain assessments are an important part of our nursing practice. Whether you work in bedside nursing, a clinic, or even telephonically, you must know and understand a variety of pain assessment tools and when to implement them.

    Numerical Rating Scale

    Most nurses and other healthcare staff are familiar with the Numerical Rating Scale (NRS). It can be administered visually or verbally.

    When using the NRS verbally, you simply ask the patient to rate their pain on a 0-10 pain scale. You must educate the patient that 0 is no pain and 10 represents the worst pain imaginable. When using the NRS visually, the same ratings are used. The patient is shown a picture of the 0 to 10 pain scale. It can be vertically or horizontally placed on the paper. Ask the patient to point to the number that best represents their pain rating.

    Visual Analogue Scale

    The Visual Analogue Scale (VAS) is a unidimensional way to measure a patient's pain. VAS can be shown to the patient in several different ways:
    • Scales created on a piece of paper that is around 10cm in length with tick-marks placed across the length of the scale. The patient is then instructed to point to the tick-mark that best represents their pain. This is then converted to a 0-10 pain rating.
    • Box-Scales - Circles are placed equal distances apart from each other and the patient chooses the one best representing their pain.
    • Wong-Baker Faces - The Wong-Baker Faces scale is commonly used with pediatric patients. Created in 2009 by Dr. Donna Wong, the Faces scale provides a picture with 6 faces that are rated from 0 to 10 running left to right. The expressions on the faces illustrate 'no hurt' up to 'hurts worst' and also run left to right, correlating with the numeric ratings.

    You explain to the patient that each face shows a person who has no pain, some pain, and a lot of pain. You then ask them to choose the face that best represents the pain they are experiencing.

    Verbal Descriptor Scale

    The use of verbal descriptions is the main idea behind the Verbal Descriptor Scale (VDS). It can be given verbally or visually. The scale has two endpoints, 'no pain' and 'very severe pain'. In between these two endpoints are 4-6 other ratings that increase in severity. Common VDS descriptions are similar to this pain scale below:
    • No pain
    • Mild pain
    • Moderate pain
    • Severe pain
    • Very severe pain

    Pain Drawing

    In the pain drawing assessment, the patient is given an outline of a human figure. You then ask them to mark the areas of pain in their body on the outline. You may ask them to circle the pain or shade the body part that is painful. Some pain drawings also ask the patient to use symbols to describe different types of pain, such as burning, stabbing, shooting, or electrifying.

    Other Considerations During a Pain Assessment: Along with assessing the patient's severity of pain, you must take into consideration a few other factors contributing to their pain. These factors include:
    Chronicity: Acute and chronic pain differ immensely. If a patient has lived with pain for many years, their tolerance to pain will be higher and this may affect their pain scale ratings.


    During a pain assessment, you must ask the patient to describe their pain. This could be sharp, shooting, electrical, or dull. These descriptors can help a physician when diagnosing the cause of pain. Try to report the pain descriptions in the patient's own words, even if it does not make sense to you.


    Find out if the patient's pain is constant or intermittent. You can also ask if anything makes the pain better or worse. For example, if the patient is suffering from an acute ankle sprain, they may report that ambulation makes the pain worse and rest, elevation, and the use of ice makes it better.

    Age of the Patient

    There are many special considerations related to the patient's age. A pediatric patient may be unable to tell you much about their pain. Older adults may have similar issues with describing the pain as well.

    Objective Signs

    During your pain assessment, look for any objective signs of pain the patient may be exhibiting. This includes facial grimacing, tachycardia, frowning, guarding, or crying out. A patient who is experiencing pain may be angry, depressed, or irritable.

    Pain ratings are subjective. You must always trust what the patient is telling you about their pain and document it using their own words when possible. Pain is an important part of your nursing assessment and can help the patient receive the correct treatment.

    What pain assessment do you use? Are there other ways that you assess pain that are helpful in your nursing practice? Comment below. We would love to hear more about your pain assessment practices.
    Last edit by Joe V on Jun 14
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  3. by   OldDude
    Well, I wasn't going to comment due to my "anti-pain scale" posts in the past but you asked...I believe pain assessment and intervention is a necessary part of patient care. I can't think of a time I've done an "adult" pain scale assessment but I have done thousands and thousands of pediatric pain assessments. So I'm not talking about grown ups. My observation is, in this population, the pain scale is regularly exaggerated and any many cases in the adolescent/teenage group is not even relevant to treatment and intervention. You had mentioned that you must always trust what the patient is telling you...picture a 15 year old sitting in your intake area, c/o of cough and congestion for 2 weeks, texting during your history with the parent, afebrile, who breaks away from the phone long enough to tell you the pain scale is "10." Sorry - that's not true and it would be doing the patient a dis-service to treat for a pain of 10. The little guys, 4/5 year olds, are the most accurate IF you can keep the parent from intervening with "their" number. Many times I have asked a kid, "is anything hurting?" and their response would be "no" but the parent will convince them otherwise. Again, no reason to treat for pain. Kids don't hide pain. They don't come to school and "suck it up" so as not to miss their educational opportunities. It seems the "Pain Pendulum" can't stop in the middle and allow a combination of subjective and objective observations to reach a reasonable pain assessment. No, I'm not saying every patient/parent falls into the category I mention above but, in my opinion, the majority of them are inaccurate.

    Of course, this is just my contribution. Thank you for the article, well written, informative and certainly compels contemplation and discussion.
  4. by   VKALA
    Well written.Many Hospital I worked,said the customer is always right.Every individual is different and represents pain in a different way.Tolerance to the pain is variable.Some are drug seekers with the pain and some are in real pain.Complicated.
  5. by   cardiacfreak
    My hospice company uses a PAINAD (Pain assessment in advanced dementia) scale.
    It rates pain based upon breathing, negative vocalizations (moaning, crying), facial expression, body language, and consolability.
  6. by   melissa.mills1117
    Hey OldDude! Thanks so much for your comments. I agree with much of what you said. It is difficult to do pain assessments. I experience the same exact thing with adults. As a telephonic case manager for folks who have been hurt at work, I often encounter people who had a lumbar sprain/strain in 2015 and still rate their pain as an 8/10. Do I fully believe this, probably not. But, I also have to try to understand more about them as a patient and a person. It is still a good indicator of their discomfort, I just have to look at context. I am often grateful I am not a physician who has to make prescribing decisions off a pain assessments.

    You make GREAT points. Thanks for commenting! ~Melissa
  7. by   melissa.mills1117
    Quote from cardiacfreak
    My hospice company uses a PAINAD (Pain assessment in advanced dementia) scale.
    It rates pain based upon breathing, negative vocalizations (moaning, crying), facial expression, body language, and consolability.
    Cardiacfreak - Thanks for this! I did not see this one in my search, however I did not look specific at hospice scales. Hospice patients are unique and have to be handled in a different way, I think. Thanks again for you comment. ~Melissa