Applies pain assessment scales (NRS, Wong-Baker, FLACC, BPS) with intervention documentation and reassessment. Use when assessing pain, selecting pain scales, or documenting pain management.
Applies pain assessment scales (NRS, Wong-Baker, FLACC, BPS) with intervention documentation and reassessment. Use when assessing pain, selecting pain scales, or documenting pain management.
Pain is designated as a fundamental focus of nursing assessment by the ANA, and effective pain management is a Joint Commission standard (PC.01.02.07). CMS Conditions of Participation require that hospitals address pain management as part of patient care. The Joint Commission revised its pain assessment standards in 2018 to emphasize individualized, multimodal approaches and to require organizations to identify patients at high risk for opioid-related adverse events. HCAHPS pain management domains affect hospital reimbursement under Value-Based Purchasing. Undertreated pain leads to delayed recovery, increased length of stay, and chronic pain development. Overreliance on opioids without appropriate assessment contributes to respiratory depression events, a leading cause of in-hospital mortality. This skill structures pain assessment, intervention selection, reassessment, and documentation per current evidence-based standards.
Patient's developmental age and cognitive status assessed
Ability to self-report determined (self-report is the gold standard per IASP)
Appropriate scale selected based on patient population
Step 1 — Select the Appropriate Pain Assessment Scale
Match the scale to the patient population:
Numeric Rating Scale (NRS) — adults and children ≥ 8 years who can self-report; 0 (no pain) to 10 (worst imaginable pain)
Wong-Baker FACES Pain Rating Scale — children ages 3–8, adults with cognitive impairment or communication barriers; patient points to face that matches their pain
FLACC Scale (Face, Legs, Activity, Cry, Consolability) — infants and children ages 2 months to 7 years, or non-verbal patients; scored 0–10 by observer
Transcutaneous electrical nerve stimulation (TENS) if ordered
Cognitive-behavioral techniques
Spiritual or cultural comfort measures per patient preference
Document which interventions were offered, accepted, and implemented.
Step 5 — Reassess Pain After Intervention
Reassessment is mandatory — an intervention without reassessment is incomplete:
IV/IM medications: reassess within 15–30 minutes of administration
Oral medications: reassess within 60 minutes of administration
Non-pharmacological interventions: reassess within 30 minutes
PCA: reassess per institutional protocol (typically q1h for first 24 hours, then q2–4h)
Document using the same scale used for initial assessment:
Pre-intervention score
Intervention provided with time
Post-intervention score with time
Whether pain goal was met
Escalate if pain goal is not met after appropriate time and dose: notify provider for order adjustment; document the escalation
Step 6 — Document the Complete Pain Assessment
Pain scale used and clinical rationale for scale selection
PQRSTU assessment findings
Severity score using the selected scale
Patient's functional pain goal
Interventions implemented (pharmacological and non-pharmacological) with times
Reassessment findings with comparison to pre-intervention score
Sedation level (POSS score) for patients receiving opioids
Patient response and satisfaction with pain management
Plan: ongoing management, anticipated needs, provider communication
Checkpoint B — Pain Management Review
Shift-Level Review
Pain assessed at required intervals (at minimum: on admission, each shift, with each new pain report, before and after interventions, before and after procedures)
Every pharmacological intervention has a documented reassessment
Sedation monitoring documented for all patients receiving opioids
Multimodal approach attempted before opioid dose escalation
Patient's functional pain goal documented and addressed
Unmet pain goals escalated to provider with documented communication
Safety Review
Opioid-naive patients monitored with increased frequency per institutional protocol
High-risk patients have capnography or enhanced monitoring if available
Naloxone availability confirmed for all opioid-receiving patients
No concurrent benzodiazepine + opioid administration without documented clinical necessity and enhanced monitoring
Quality Audit
Pain assessment documented per institutional frequency requirements
Appropriate scale selected and consistently used for each patient
PQRSTU comprehensive assessment documented on admission and with each new pain complaint
Reassessment documented within appropriate timeframe for every intervention
Sedation scale (POSS) documented for all opioid-receiving patients
HCAHPS: Pain management communication domain — did staff do everything they could to help with pain; were new medications explained
Scope of practice: RN independently assesses pain, selects appropriate scale, implements non-pharmacological interventions, administers analgesics per order, evaluates effectiveness, and advocates for order modification; LPN/LVN may collect pain data and implement interventions under RN direction per state Nurse Practice Act
Opioid stewardship: Document morphine milligram equivalents (MME), screen for risk factors, use multimodal first-line approaches, and monitor for adverse events including respiratory depression and sedation
