Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Pain Assessment

Practice Recommendations: 

Part A – Assessment Recommendations

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Screening for Pain 

Recommendation 1
Screen all persons at risk for pain at least once a day (when undertaking other routine assessments), by asking the person or family/care provider about the presence of pain, ache or discomfort. In situations where the individual is non-verbal, use behavioural indicators to identify the presence of pain.

Grade of Recommendation = C

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Parameters of pain assessment 

Recommendation 2
Self-report is the primary source of assessment for verbal, cognitively intact persons. Family/care provider reports of pain are included for children and adults unable to give self-report.

Grade of Recommendation = C

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Recommendation 3
A systematic, validated pain assessment tool is selected to assess the following basic parameters of pain:

  • location of pain;
  • effect of pain on function and activities of daily living (i.e., work, interference with usual activities, etc.);
  • level of pain at rest and during activity;
  • medication usage and adverse effects;
  • provoking or precipitating factors;
  • quality of pain (what words does the person use to describe pain? - aching, throbbing);
  • radiation of pain (does the pain extend from the site?);
  • severity of pain (intensity, 0-10 scale), pain related symptoms; and timing (occasional, intermittent, constant).

Grade of Recommendation = C

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Recommendation 4
A standardized tool with established validity is used to assess the intensity of pain.

  • Visual Analogue Scale (VAS);
  • Numeric Rating Scale (NRS);
  • Verbal Scale;
  • Faces Scale;
  • Behavioural Scale

Grade of Recommendation = A

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Recommendation 5
Pain assessment in patient populations who are unable to give self-report (non-communicative) may include behavioural indicators using standardized measures and physiological indicators where appropriate.

Grade of Recommendation = C

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Comprehensive pain assessment 

Recommendation 6
The following parameters are part of a comprehensive pain assessment:

  • physical examination, relevant laboratory and diagnostic data;
  • effect and understanding of current illness;
  • history of pain;
  • meaning of pain and distress caused by the pain (current and previous);
  • coping responses to stress and pain;
  • effects on activities of daily living;
  • psychosocial and spiritual effects;
  • psychological - social variables (anxiety, depression);
  • situational factors - culture, language, ethnic factors, economic effects of pain and treatment;
  • person's preferences and expectations/beliefs/myths about pain management methods; and
  • person's preferences and response to receiving information related to his/her condition and pain.

Grade of Recommendation = C

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Reassessment and ongoing assessment of pain

Recommendation 7
Pain is reassessed on a regular basis according to the type and intensity of pain and the treatment plan.

  • Pain intensity and function (impact on activities) is reassessed at each new report of pain and new procedure, when intensity increases, and when pain is not relieved by previously effective strategies.
  • Effectiveness of intervention (both pharmacological and non-pharmacological) is reassessed after the intervention has reached peak effect (e.g., for opioids: 15-30 minutes after parenteral opioid therapy; 1 hour after immediate release analgesic).
  • Acute post-operative pain should be regularly assessed as determined by the operation and severity of pain, with each new report of pain or instance of unexpected pain, and after each analgesic, according to peak effect time.

Grade of Recommendation = C

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Recommendation 8
The following parameters should be monitored on an ongoing basis in persistent pain situations:

  1. current pain intensity, quality and location;
  2. intensity of pain at its worst in past 24 hours, at rest and on movement;
  3. extent of pain relief achieved - response (reduction on pain intensity scale);
  4. barriers to implementing the treatment plan;
  5. effects of pain on ADL's, sleep and mood;
  6. adverse effects of medications for pain treatment (e.g., nausea, constipation);
  7. level of sedation; and
  8. strategies used to relieve pain, both pharmacological and non-pharmacological.

Grade of Recommendation = C

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Recommendation 9
Unexpected intense pain, particularly if sudden or associated with altered vital signs such as hypotension, tachycardia, or fever, should be immediately evaluated.

Grade of Recommendation = C

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Documentation of pain assessment

Recommendation 10
Document on a standardized form that captures the person's pain experience specific to the population and setting of care. Documentation tools will include:

  • Initial assessment, comprehensive assessment and re-assessment.
  • Monitoring tools that track efficacy of intervention (0-10 scale).

Grade of Recommendation = C

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Recommendation 11
Document pain assessment regularly and routinely on standardized forms that are accessible to all clinicians involved in care.

Grade of Recommendation = C

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Recommendation 12
Teach individuals and families (as proxy recorders) to document pain assessment on the appropriate tools when care is provided. This will facilitate their contributions to the treatment plan and will promote continuity of effective pain management across all settings.

Grade of Recommendation = C

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Communicating findings of pain assessment

Recommendation 13
Validate with persons/care providers that the findings of the pain assessment (health care provider's and person's/care provider's) reflect the individual's experience of pain.

Grade of Recommendation = C

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Recommendation 14
Communicate to members of the interdisciplinary team pain assessment findings by describing parameters of pain obtained through the use of a structured assessment tool, the relief or lack of relief obtained from treatment methods and related adverse effects, person's goals for pain treatment and the effect of pain on the person.

Grade of Recommendation = C

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Recommendation 15
Advocate on behalf of the person for changes to the treatment plan if pain is not being relieved. The nurse will engage in discussion with the interdisciplinary health care team regarding identified need for change in the treatment plan. The nurse supports his/her recommendations with appropriate evidence, providing a clear rationale for the need for change, including:

  • intensity of pain using a validated scale;
  • change in severity pain scores in last 24 hours;
  • change in severity and quality of pain following administration of analgesic and length of time analgesic is effective;
  • amount of regular and breakthrough pain medication taken in last 24 hours;
  • person's goals for pain relief;
  • effect of unrelieved pain on the person;
  • absence/presence of adverse effects or toxicity; and
  • suggestions for specific changes to the treatment plan that are supported by evidence.

Grade of Recommendation = C

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Recommendation 16
Provide instruction to the person/care provider on:

  • the use of a pain log or diary (provide a tool); and
  • communicating unrelieved pain to the appropriate clinician and supporting them in advocating on their own behalf.

Grade of Recommendation = C

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Recommendation 17
Report situations of unrelieved pain as an ethical responsibility using all appropriate channels of communication in the organization, including individual/care provider documentation.

Grade of Recommendation = C

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Recommendation 18
Refer persons with persistent pain whose pain is not relieved after following standard principles of pain management to:

  • a clinical team member skilled in dealing with the particular type of pain;
  • a multidisciplinary team to address the complex emotional, psycho/social, spiritual and concomitant medical factors involved.

Grade of Recommendation = C

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