A pain score is the beginning of an assessment, not its conclusion. When a patient says that pain prevents them from turning, coughing or sleeping, the nurse needs to understand both the discomfort and its effect on recovery. A useful care plan connects the patient's account with assessment findings, safe interventions and a clear reassessment.
- Gather a structured pain history and select an appropriate assessment tool.
- Link comfort goals to activities that matter to the patient.
- Plan nursing actions, reassess their effect and communicate concerns.
- Write a care note that shows the assessment–action–evaluation sequence.
1. Understanding pain in nursing practice
Pain is an individual experience. Patients can describe similar conditions very differently, and a calm appearance does not establish that pain is absent. NHS Highland's pain-assessment guidance emphasises self-report when appropriate and considers pain during activity as well as at rest. Start by listening to the person rather than deciding how much pain they should have.
For study purposes, distinguish a new episode from an established pain problem. Ask what is usual for the patient and what has changed today. A person with long-standing pain can develop a new, unrelated problem; avoid assuming that every new symptom belongs to an existing diagnosis. NICE recommends reassessment when chronic pain symptoms change and review of the support plan. This article focuses on general adult assessment and a fictional postoperative learning example, rather than treatment of every pain condition.
2. Begin with a structured assessment
Introduce yourself, explain what you are assessing and obtain the patient's cooperation. Establish a way to communicate that works for the person, including language or sensory support where needed. Ask about the pain directly, then use a structured history to organise the conversation. The UK Nursing and Midwifery Council's assessment criteria use PQRST alongside comfort measures, communication, reassessment and documentation.
| Element | Original example questions | What to record |
|---|---|---|
| P — Provoking / relieving factors | “What makes it worse? What has helped so far?” | Triggers, position, activity and response to previous measures. |
| Q — Quality | “How would you describe the feeling?” | The patient's own words, such as aching, burning or sharp. |
| R — Region / radiation | “Point to where it hurts. Does it travel anywhere?” | Location and any spread to another area. |
| S — Severity | “Using this scale, how strong is the pain at rest and when you move?” | The tool used, score and activity during assessment. |
| T — Timing | “When did it begin? Is it constant or does it come and go?” | Onset, duration, pattern and change from baseline. |
Complete the picture by asking what the pain stops the patient from doing and what they hope to do more comfortably. Review relevant observations and the existing clinical plan. A changing pain pattern warrants attention even when a numerical score has not changed. When reporting your assessment, distinguish the patient's account from what you observed.
3. Choose a tool the patient can use
Self-report when communication is possible
A numerical scale can be useful for a person who understands and can use it. Explain its anchors and use it consistently during follow-up. A verbal description may be more accessible for some adults. Assessment guidance for older people recommends adapting communication and offering suitable self-report tools rather than assuming that age or a diagnosis prevents participation.
When self-report is limited
First explore whether the person can communicate with assistance. If reliable self-report remains unavailable, use a validated observational approach suited to the patient and setting, following local policy. Familiar carers can help describe behaviours that differ from the person's usual state. The ASPMN recommendations caution that vital signs alone cannot establish the presence or absence of pain. They are cues for further assessment, not a replacement for it.
4. Set nursing priorities and meaningful goals
Use the findings to identify the patient's care needs rather than choosing a diagnosis from the title of an article. A pain-related nursing problem should be supported by the actual assessment and linked to an appropriate care plan. Use the terminology and current classification required by your institution; the example below is a learning formulation, not a quotation of a proprietary nursing diagnosis definition.
Agree an achievable goal with the patient. For example, “The patient will be able to turn in bed with assistance and describe whether the comfort plan is helping at the next review.” This is more informative than writing only “pain will reduce.” The 2024 Association of Anaesthetists and British Pain Society consensus places postoperative pain management within recovery and function, rather than relying on a single intensity score.
5. Nursing interventions and rationales
| Nursing action | Rationale / evaluation focus |
|---|---|
| Listen to the patient's description and establish a baseline before an intervention. | A documented starting point makes a later comparison meaningful. Ask about the activity the patient wishes to attempt. |
| Assist with a comfortable position that is safe for the condition and procedure. | Comfort measures can support the care plan. Check whether the position actually helps rather than assuming it does. |
| Review what pain-relief measures and medicines have already been given. | This supports an informed handover and helps avoid acting without knowing the current plan. |
| Administer prescribed analgesia only after the required identity, prescription, allergy and safety checks. | Medication care must follow the individual prescription and local monitoring arrangements. This guide does not supply doses or substitute for prescribing decisions. |
| Explain the agreed plan in understandable language and invite questions. | The patient should know what is planned and how to request help. Check understanding rather than assuming that an explanation has been understood. |
| Reassess both comfort and relevant function after the intervention. | A change in the score alone does not show whether the patient can undertake the agreed activity. |
| Communicate persistent pain, new findings or treatment-related concerns promptly. | The team may need to reassess the cause or revise the plan. Follow the escalation pathway appropriate to the urgency. |
Multimodal postoperative pain care combines approaches rather than relying on one intervention. The prescribed combination depends on the procedure, clinical circumstances and contraindications. Nurses contribute through assessment, delivery of the authorised plan, monitoring and communication. Do not independently add, increase or repeat a medicine merely to reach a numerical score.
Know when routine comfort care is insufficient
A patient who becomes difficult to rouse, develops slow or abnormal breathing, or shows another sign of acute deterioration needs urgent assessment and escalation through the local emergency pathway. New severe pain with concerning findings should not be treated as a routine request to “wait for the next round.” Prioritise immediate clinical assessment over finishing documentation or a teaching exercise.
6. Sample nursing care plan: fictional postoperative case
Scenario: An adult recovering from surgery says, “It hurts when I try to turn.” The person describes incisional aching, reports a rest score of 4/10 and movement score of 7/10, and needs help to change position. The following numbers are invented for teaching; they are not research data or a patient record.
| Care-plan component | Example entry |
|---|---|
| Assessment cues | Patient describes pain at the incision, increased by turning, and hesitates to move. Record relevant observations and assessment findings from the actual encounter. |
| Identified nursing problem | Pain affecting comfort and ability to reposition following surgery. |
| Agreed outcome | At the planned review, the patient will describe the response to care and attempt an assisted turn within the postoperative activity plan. |
| Planned actions | Explain the plan; review prescribed treatment and previous administration; assist with supported positioning; deliver authorised interventions; reassess and report unresolved concerns. |
| Evaluation | Document the reassessment score using the same tool, the patient's account, ability to turn and any adverse effects. Mark the goal met, partly met or unmet using the observed outcome. |
Suppose the patient later reports 3/10 at rest but still cannot turn because of pain. It would be misleading to write “goal achieved” simply because the rest score fell. The next step is to communicate the continuing functional limitation and review the plan with the appropriate clinician. In contrast, if the patient can turn with help but reports an unwanted effect, record both findings. Benefit and safety must be considered together.
7. Reassessment, documentation and handover
Plan reassessment at a clinically appropriate time for the intervention and sooner if the patient's condition changes. The ASPMN recommendations relate post-intervention assessment to the expected effect of the treatment; a single universal interval is not suitable for every medicine, route or non-drug measure. Follow the prescribed monitoring plan and local policy.
A clear record answers four questions: What did the patient report? What did you assess? What action was taken? What happened afterward? Include the time, assessment method, relevant function, intervention and response. Where escalation was necessary, record who was contacted, the concern communicated and the agreed next step.
“Patient reports incisional aching, worse on turning; numerical scale 4/10 at rest and 7/10 with movement. Supported positioning and prescribed pain-care plan implemented following required checks; see medication chart. At planned reassessment, patient reports 3/10 at rest and 5/10 during assisted turn. Turn completed with help. Further review arranged because movement remains uncomfortable.”
The example illustrates structure only. In practice, use actual times and findings, identify the intervention precisely and document required safety observations.
Common mistakes to avoid
- Using a calm appearance or normal observations to dismiss a patient's report.
- Recording only a number without the tool, context or effect on activity.
- Copying a previous care-plan evaluation without reassessing.
- Writing “analgesia effective” without showing what changed.
- Applying an adult teaching example to a child or another population without the appropriate guidance.
8. Quick review questions
1. A patient is comfortable at rest but cannot cough because of pain. Has assessment finished?
No. Explore pain during the relevant activity and its effect on recovery, then communicate and evaluate the individual plan. A rest score alone is incomplete.
2. Do unchanged vital signs exclude pain?
No. Use the patient's report whenever possible, or an appropriate validated behavioural approach when self-report is unavailable.
3. What should follow a pain intervention?
A planned reassessment of benefit, relevant function and safety, followed by documentation and escalation if needed.
References and further reading
- UK Nursing and Midwifery Council: Adult nursing OSCE marking criteria — pain assessment.
- NHS Highland: Pain assessment guidance.
- The Assessment of Pain in Older People: UK National Guidelines.
- Pain assessment in the patient unable to self-report: recommendations supporting the ASPMN 2024 position statement.
- El-Boghdadly et al. (2024): Peri-operative pain management in adults — multidisciplinary consensus statement.
- NICE NG193: Chronic pain assessment recommendations.
Prepared for nursing education. Adapt assessment and care to the individual, your scope of practice and current local policy. This original Mini Nurses guide is not affiliated with Nurseslabs or an examination regulator.