Reference — Pain Management

Pain Assessment Reference

Pain is a subjective experience — the nurse's role is to believe the patient, assess accurately, intervene appropriately, and reassess. This reference covers the major validated scales and the nursing framework for comprehensive pain assessment.

Educational use only. Pain assessment and management decisions require clinical judgment and must follow institutional protocols and the licensed provider's plan of care. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Choosing the Right Scale

Scale	Population	Requirement
NRS (0–10)	Adults, verbal	Patient can self-report and understand numeric scale
Wong-Baker FACES	Children (3+), cognitive impairment	Patient can point to a face; can self-report
FLACC	Infants, pre-verbal children (0–7 yr)	Observational; no patient self-report required
CPOT	Adult ICU patients, non-verbal	Observational; used with ventilated / sedated adults

Numeric Rating Scale (NRS 0–10)

Ask the patient: “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, how would you rate your pain right now?”

Score	Severity	Typical Action
0	No pain	Document; continue assessment per schedule
1 – 3	Mild	Non-pharmacological measures; reassess; PRN analgesia if ordered
4 – 6	Moderate	Administer analgesia per order; reassess in 30–60 min
7 – 10	Severe	Administer analgesia; notify provider; reassess frequently

A goal pain score should be established collaboratively with the patient. “Acceptable” pain is individual — aim for the patient's functional goal, not a universal target.

FLACC Scale (Infants & Pre-Verbal Children)

Category	0	1	2
Face	No particular expression or smile	Occasional grimace, furrowed brow, withdrawn	Frequent to constant frown, clenched jaw, quivering chin
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking or legs drawn up
Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense	Arched, rigid, or jerking
Cry	No cry (awake or asleep)	Moans or whimpers, occasional complaint	Crying steadily, screaming, frequent complaints
Consolability	Content, relaxed	Reassured by touching/hugging; distractible	Difficult to console or comfort

0: Relaxed / comfortable1–3: Mild discomfort4–6: Moderate pain7–10: Severe pain

Critical Care Pain Observation Tool (CPOT)

Indicator	0 — No pain behavior	1	2 — Pain behavior present
Facial Expression	Relaxed, neutral	Tense	Grimacing
Body Movements	Absence of movements or normal position	Protection	Restlessness
Muscle Tension	Relaxed, no resistance to passive movement	Tense, rigid	Very tense or rigid
Ventilator Compliance	Tolerating ventilator or movement	Coughing, but tolerating	Fighting ventilator
Vocalization (non-intubated)	Talking in normal tone	Sighing, moaning	Crying out, sobbing

Total score: 0 (no pain) to 8 (maximum pain). A score of ≥ 3 indicates significant pain requiring intervention. Used with RASS and SAS sedation scales.

Comprehensive Pain Assessment — OLDCARTS

Letter	Element	Sample Question
O	Onset	When did the pain start?
L	Location	Where is the pain? Does it radiate?
D	Duration	Is it constant or intermittent? How long does it last?
C	Character	Describe the pain — sharp, dull, burning, crushing, aching?
A	Alleviating / Aggravating	What makes it better or worse?
R	Radiation	Does it travel anywhere — arm, jaw, back?
T	Timing	When does it occur — at rest, with activity, at night?
S	Severity	Rate on a 0–10 scale. What is your goal score?

Non-Pharmacological Interventions

These measures complement but do not replace ordered analgesia. Always incorporate them alongside pharmacological management.

● Repositioning / comfort positioning● Heat or cold therapy (per order/protocol)● Distraction techniques (TV, music, guided imagery)● Relaxation and deep breathing● Massage (back rub)● TENS (transcutaneous electrical nerve stimulation)● Elevation of affected limb● Oral care / dry mouth relief● Dim lighting / quiet environment● Splinting the incision site for movement

Reassessment Guidelines

Intervention	Reassess In
IV / IM analgesic	15 – 30 minutes
Oral analgesic	30 – 60 minutes
Non-pharmacological measure	15 – 30 minutes
Epidural / PCA	Per institutional protocol (often q1–2h)
Stable / no intervention	Per unit assessment schedule (typically q4–8h)

Document the intervention, timing, reassessment score, and patient response every time.

Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with American Nurses Association (ANA) Standards of Practice · The Joint Commission. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →