Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Pain Assessment

• Nurses have an important role in screening for pain on admission or visit with a health-care professional, after a change in their medical status and prior to, during and after a procedure. If the screen is positive, a comprehensive assessment of the person’s pain experience is required.

• It is important for the nurse to ask directly about pain rather than assuming the person or their family or caregivers will volunteer the information.

• Nurses should use a consistent, systematic approach to exploring and assessing pain. An acronym (link to Figure 1 pg 22) that uses the mnemonic OPQRSTUV can be used to systematically explore and assess people able to self-report the presence or risk of, any type of pain.

• Comprehensive assessment includes determining the quality and severity (intensity) of pain.

• Self-report tools may be uni-dimensional or multidimensional (Link to Appendix E pg 82-82).

• Every attempt should be made to obtain the person self-report, however behavioural indicators or behavioural pain scales validated for the specific populations and contexts should be used (Link to Appendix H, I, J, K, L, M – pg 89-95) and with any proxy reporting from family or caregivers.

• Vital signs should not be used as an indicator for presence of pain.

• Validated tools should be used for assessment of pain in special populations.

• Assessment also includes exploring a person, their family or caregiver’s knowledge and misbeliefs about pain and pain management.

• All assessment findings should be documented and communicated to the interprofessional team to create a plan of care.