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Medical-Surgical Nursing · Chapter 4

The Pain Assessment Bench

Self-report is the standard and it is not negotiable — but the correct scale is the one the patient can actually use, and the same tool must be used every shift or the trend means nothing. Match the tool to the patient, read the score against its real action threshold, then switch to Dose or diagnosis and decide which pain complaints are a medication and which are an emergency.
Pick a patient
Which validated tool do you reach for?
Score the patient
You are about to medicate. Which route?
Seven pain calls. Dose, or diagnosis?
Start on the left
Choose a patient, then choose the tool you would actually document on.

The hierarchy of pain assessment

Use it in this order, every time
  • Attempt self-report first — always, even in dementia and even when you doubt you will get an answer.
  • Look for pathology known to be painful: a fracture, a fresh incision, a pressure injury, a distended bladder.
  • Observe behaviours with a validated tool — FLACC, CPOT, BPS or PAINAD.
  • Ask the family or caregiver who knows this person’s baseline.
  • If the situation would hurt anyone, offer an analgesic trial and evaluate the behavioural response.
Two rules students lose marks on
Normal vital signs never rule out pain. In persistent pain the autonomic system adapts, so tachycardia and hypertension are typically absent. And pain was retired as “the fifth vital sign” because a number alone is not an order for an opioid — assess intensity, function, sedation and respiratory status together, and ask for a functional goal: “what number lets you take a deep breath, cough and walk to the bathroom?”