Nursing assessment tools for pain assessment

Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Physiological indicators in isolation cannot be used as a measurement for pain. A tool that incorporates physical, behavioural and self report is preferred when possible.

These include:. Further information on pain management principles and assessing pain in children can be found here:. The evidence table for this guideline can be viewed by clicking here. Please remember to read the disclaimer. Updated February Nursing Standard. Alternatively, you can purchase access to this article for the next seven days. Buy now. It is concluded that the use of pain assessment tools is advantageous, and the reasons why they are not used more widely are considered According to Walker and Campbell 1 , pain assessment and control should be a priority within nursing.

Want to read more? Already subscribed? According to one performance and improvement outpatient project in , areas for improvement in pain reassessment policies and procedures were identified in a clinic setting.

The study concluded compliance rates for the minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record EHR design played a role in low compliance with the reassessment of pain.

Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators KPIs to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols.

The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment. Asking about how the client feels and their response to those feelings is part of a psychological assessment.

Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression.

The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:. Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered.

Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk. In the fast-paced, resource-challenged healthcare environment today, thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care.

The importance of a head-to-toe assessment, critical thinking skills guided by research, and therapeutic communication are the mainstays of safe practice. Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse.

Communicating in a concise, efficient manner in rapidly changing situations and deteriorating patient conditions can promote quick solutions during difficult circumstances. Healthcare providers communicate and share in the decision-making process. The SBAR model facilitates this communication between members of the healthcare team and bridges the gap between a narrative, descriptive approach and one armed with exact details.

This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Last Update: August 30, Analysis or diagnosis formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient. Issues of Concern The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.

Admission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatient. Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility. Documentation and signature either written or electronic by the nurse performing the assessment. Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information two patient identifiers.

Allergies: Medications, foods, and environmental; nature of the reaction and seriousness; intolerances to medications; apply allergy band and confirm all prepopulated allergies in the electronic medical record EMR with the patient or caregiver.

Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies; include supplements and over-the-counter medications. Main outcomes included the number and types of domains captured by each instrument e. Results: Our search identified eight multidimensional assessment tools, all of which measured sensory or affective qualities of pain and its impact on functioning.

Most tools measured impact of pain on affective functioning, mood, or enjoyment of life.