Nursing Assessment for Pain

Sunday, December 11, 2011

Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."

It motivates withdrawal from damaging or potentially damaging situations, protection of a damaged body part while it heals, and avoidance of similar experiences in the future. Most pain resolves promptly once the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease.

Pain is the most common reason for physician consultation in the United States. It is a major symptom in many medical conditions, and can significantly interfere with a person's quality of life and general functioning. Psychological factors such as social support, hypnotic suggestion, excitement in sport or war and distraction can significantly modulate pain's intensity or unpleasantness.

Nursing Assessment of Pain

Assessment of pain is factual and accurate information is required to:

  • Establish a baseline
  • Appropriate nursing diagnosis
  • Selecting a suitable therapy
  • Evaluate client response to therapy given
Nurses need to explore the experience of pain from the viewpoint of the client. The advantage for clients pain assessment is that the pain is identified, recognized as something tangible, measurable, can be explained, and used to evaluate treatment.

Things that need to be studied are as follows:
  1. Expression of the client to pain
    Many clients do not report / discuss the condition of discomfort. For that nurses must learn how verbal and nonverbal clients in communicating a sense of discomfort. Clients who are unable to communicate effectively often requires special attention when the assessment.
  2. Classification of pain experience
    Nurses assess whether the client felt the pain of acute or chronic. When acute, it takes a detailed assessment of the characteristics of pain and when pain is chronic, then the nurse to determine whether ongoing intermittent pain, persistent or limited.
  3. Characteristics of pain
    • Onset and duration. Nurses assess how long the pain is felt, how often pain relapse, and whether the appearance of pain at the same time.
    • Location. The nurse asks the client to indicate where the pain is felt, or feels settled on spread
    • Severity. The nurse asks the client describes how severe the pain is felt. To obtain these data the nurse can use assistive devices, measuring scales. Clients indicated the scale of measurement, then given the choice to suit current conditions. Measuring scale can be a numeric scale, descriptive, visual analogue.
  4. Effects of pain on the client
    Pain is stressful and can change the lifestyle and psychological well-being of individuals. Nurses should review the following things to determine the effect of pain on the client:
    • Signs and symptoms of physical
      Nurses assess the physiological signs, because of the pain that is felt the client could have an effect on the normal functioning of the body.
    • Behavioral effects
      Nurses assess verbal response, body movements, facial expressions, and social interaction. Verbal report of pain is a vital part of the assessment, nurses must be willing to listen and try to understand the client. Not all clients are capable of expressing the pain that is felt, for things like that nurses should be aware of client behaviors that indicate pain.
    • Effects on ADL
      Clients who experience pain are less able to participate in regular daily activities. This assessment indicates the extent of the adjustment process the client capabilities and participate in self-care. It is important also to assess the effects of pain on the client's social activities.
  5. Neurological status
    Neurological function more easily influence the pain experience. Any factors that interfere with or affect the reception and perception of pain that would normally affect the client's responses and awareness of pain. It is important for nurses to assess the neurological status of the clients, because clients who have neurological disorders are not sensitive to pain. Preventive action needs to be done on the client with a neurological disorder that easily injured.

Source :

Nursing Care Plan for Pain - Assessment, Diagnosis and Interventions


NANDA - Nursing Diagnosis

Nursing Care Plan

Nursing Care Plan