Pain Assessment in Nursing: Tools, Types, and PQRST

Pain assessment is a cornerstone nursing skill and is often called the fifth vital sign. This note reviews the core definitions, types of pain, structured assessment methods (PQRST and OLDCARTS), the tools to use in different populations, and the exam traps that commonly trip up students.

Core Definitions

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is always subjective and is whatever the patient says it is.
• Pain assessment is the systematic evaluation of a patient's pain experience using appropriate tools. It is often called the fifth vital sign.

Pain Assessment Tools

• Numeric Rating Scale (0–10) — Best for adults who can self-report. Patient rates pain from 0 (no pain) to 10 (worst pain).
• Wong-Baker FACES Scale — Best for children or patients with language barriers. Six faces from smiling (0) to crying (10).
• FLACC Scale — Best for infants or nonverbal patients. Observes Face, Legs, Activity, Cry, Consolability.
• PAINAD Scale — Best for patients with dementia. Observes breathing, negative vocalization, facial expression, body language, and consolability.
• CRIES Scale — Best for neonates. Observes Crying, Requires O₂, Increased vital signs, Expression, Sleeplessness.

Types of Pain

• Acute pain — Sudden onset, lasts less than 3–6 months. Serves as a warning sign of tissue damage and resolves with healing.
• Chronic pain — Persists beyond normal healing time, typically longer than 3–6 months. May have no identifiable cause or protective function.
• Nociceptive pain — Results from damage to somatic or visceral tissue.
  • Somatic: sharp and localized.
  • Visceral: dull, aching, and diffuse.
• Neuropathic pain — Results from damage to the nervous system itself. Often described as burning, shooting, or tingling.
• Breakthrough pain — Transient flare of moderate to severe pain on a background of controlled baseline pain.
• Referred pain — Felt at a location distant from the source (e.g., left arm pain during a myocardial infarction).

PQRST Method

• P — Provocative/Palliative: What makes it worse? What makes it better?
• Q — Quality: What does the pain feel like? (sharp, dull, burning, crushing, throbbing)
• R — Region/Radiation: Where is the pain? Does it travel anywhere?
• S — Severity: Rate the pain 0–10.
• T — Timing: When did it start? Constant or intermittent?

OLDCARTS Method

• O — Onset: When did the pain begin?
• L — Location: Where is the pain?
• D — Duration: How long does it last?
• C — Character: What does it feel like?
• A — Aggravating factors: What makes it worse?
• R — Relieving factors: What makes it better?
• T — Timing: When does it occur?
• S — Severity: Intensity on a 0–10 scale.

Pain Assessment in Special Populations

• Infants and young children cannot self-report reliably — use FLACC or CRIES based on behavioral observations.
• Older adults with dementia may struggle with numeric scales — use PAINAD.
• Patients with language barriers can use the FACES scale. Never use a family member as an interpreter for pain assessment — use a certified interpreter.
• Nonverbal patients require behavioral indicators such as grimacing, guarding, moaning, or restlessness. Vital signs may also change.

Common Myths About Pain

• Myth: Patients who are sleeping cannot be in pain.
  • Fact: Patients in pain can fall asleep from exhaustion.
• Myth: Vital signs always change with pain.
  • Fact: Chronic pain and certain medications can blunt vital sign changes.
• Myth: A patient's behavior reflects their pain level.
  • Fact: Some patients do not show outward signs of pain.
• Myth: Older adults feel less pain.
  • Fact: Pain perception does not decrease with age.

Factors Affecting Pain Perception

• Physiological: age, fatigue, genetics, neurological function. Fatigue lowers pain tolerance.
• Psychological: anxiety, fear, depression, coping style. Anxiety increases pain perception.
• Cultural: beliefs about pain expression — some cultures encourage stoicism, others verbal expression.
• Social: attention, support systems, previous pain experiences. Lack of support increases suffering.

Common Exam Traps

• Do not assume a smiling or sleeping patient has no pain — pain is subjective.
• Do not rely solely on vital signs, especially in chronic pain.
• Do not use a numeric scale with a child under age 5 or a patient with dementia — use FACES or PAINAD instead.
• Do not use a family member as an interpreter for pain assessment.
• Do not undermedicate based on assumptions about addiction risk. Treat pain based on the patient's report.
• Do not document "patient appears comfortable" without asking the patient to rate their pain. Self-report is the gold standard.

Key Takeaways

• Pain is always subjective and whatever the patient says it is — it is the fifth vital sign.
• Acute pain lasts <3–6 months and resolves with healing; chronic pain persists beyond normal healing time.
• Use PQRST or OLDCARTS to assess pain systematically.
• Match the tool to the patient: FACES for children, FLACC for nonverbal infants, CRIES for neonates, PAINAD for dementia.
• Never use a family member as an interpreter for pain assessment.
• The patient's self-report — not vital signs or appearance — is the gold standard.