How Nurses Should Document Pain
Updated: Aug 10, 2021
As nurses, we're constantly being told that we need to monitor our patient's pain. But how should we do that? In this blog post, I'll break it down for you so you can really get to the crux of understanding patient pain documentation.
First, let's look at what we identify as "pain," and then dissect what we need to do make sure we are documenting our care for our patients.
To paraphrase Merriam-Webster, pain is an unpleasant response (or series of responses) that result in mild to extreme discomfort in patients.
As nurses, we have to remember that, because pain is a subjective response, we have to take a patient at their word. But we also have some intuitive responses that help us to figure out how true or accurate a patient's pain level is.
First, many patients who have acute pain will have it manifest as a physiologic response. While many patients can have a high pain tolerance, many can't handle acute breakthrough pain that exceeds what they consider a comfortable threshold.
As an example, I'll use an experience that I had myself a few years back...
When my wife and I were preparing for my wedding, I was hell-bent on getting in top physical shape. After a foolish move at the gym, I thought I pulled a muscle. A few days later, I thought a massage would help. It didn't. But I did experience a physiologic response to pain that included profuse diaphoresis, nausea, and tachycardia (I'm sure my BP was sky-high too).
The big takeaway is simply that if a patient says they're in pain, there are often other physiologic signs to confirm it.
Likewise, the opposite can occur. A patient can experience severe acute pain, and have a high pain tolerance that eludes the physiologic response. So that's why it's important to not only ask the patient what their pain is, but also to take into account those vital signs.
Pain Scale vs Sedation Scale
There's an important distinction to be made between pain and sedation scales. In practice, many providers (not only nurses) get confused between the two when it comes to documentation. While pain management with medications can contribute to sedation, they are two entirely different things.
Sedation scales are tools used to determine the patient's sedation in response to narcotics or other medication that are used to find out if sedation is safe or if more is needed (such as in the use of sedatives for ventilation management in the ICU).
Pain scales are tools used to determine the patient's level of pain so that the nurse can alleviate or reduce the patient's pain level.
Sedation plays a role in patient safety, whereas pain scales are used to find out how much a patient hurts. These tools are meant to guide practice, not replace it.
For more info on sedation scales, head over to this blog post to find out more about RASS vs POSS.
What is a pain scale, exactly?
Well, a pain scale is really a point of reference to help us determine how severe or mild a patient's discomfort is, and what steps we should take to do it. The problem is that there are a variety of patient situations or conditions that either allow us or prevent us from determining what a patient's actual pain discomfort is. So let's look at some of the common ones.
This one is really straightforward. The way that I really approach this is to ask the patient: "On a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you've ever felt, how bad is your pain right now?"
By giving them a numerical range, they can then give you a point of reference. You may have pain medications that you can give based on the answer you receive, or sometimes you'll need to employ the use of non-pharmacological interventions (think ice, positioning, guided imagery, etc.).
One key note here, is to make sure you ask the patient what their acceptable level of pain is. Meaning, at what level does the patient need medication or some other intervention. By asking this, especially at the start of your shift, you'll really help to determine some critical patient goals.
Nonverbal Pain Scale (AKA Adult NVPS)
This pain scale is quite different than the verbal pain scale. With this pain scale, you'll need to use some sort of tool to determine what level of pain the patient is in, such as the Adult Non-Verbal Pain Scale (NVPS). This uses a scoring system to calculate a patient's pain level. It uses criteria such as facial responses, guarding, vital signs, movement, and respiratory physiology to calculate a score.
For every category, evaluate the patient and give them a score. For example, a patient who has an occasional grimace (1 point), lying quietly (0 points), who is tense or guarding (1 point), with an increase in SBP of 22 over baseline (1 point) and is baseline respiratory rate (0 points) would receive a pain score of 3!
After utilizing this tool and assessing your patient, you can document the way you came to determine your patient's pain level. The NVPS and FLACC are similar in that they are using a tool to determine pain in a patient that cannot communicate effectively or easily with nursing staff.
FLACC is very similar to the NVPS in that it uses a scoring system to determine patient's pain levels. The difference is that FLACC is used in the pediatric and children's areas. It's used for patients aged 2 months to 7 years. At 7 years, many children can verbalize pain, and many will use the verbal pain scale.
FLACC focuses on five areas: facial responses, leg movement, activity, crying, and consolability. Depending on their response, they receive 0 to 2 points for every category, with 0 being no pain, and 10 points equaling severe pain.
Visual Pain Scale
The visual pain scale is the pain scale that fits in when you can't really otherwise use any other tools. The purpose of this pain scale is to provide patients who cannot verbalize pain, or who can point or mark on a continuum, a method of communicating their
Sometimes patients with ALS, dementia, some children (via the Wong-Baker scale), or ventilated patients who are awake, can demonstrate to you how much discomfort they are in.
The Wong Baker scale should be used in patients who are ages 3 and over. For those patients who are adults and would rather mark their pain level based on a spectrum/continuum, you can use this scale as well.
One challenge with the latter is that there is not really an objective value. The best method to combatting this is to basically divide the line in half (and give that a value of 5), and then make small, subjective estimates on the patient's pain level. Unless your facility uses a specific tool for visual pain scale patients, the Wong-Baker can be used in those patients who are also mentally impaired or have decreased communication.
Keys to Great Pain Documentation
The biggest challenge that nurses and nursing students have when documenting pain is understanding the critical elements. Every time pain is documented it should include the following:
Pain level (and pain scale used)
Sedation scale (and sedation scale used)
Quality and location of pain (use something like PQRST** to help guide you)
Any non-pharmacological interventions used
Any pharmacologic interventions used
Some sort of evaluation
** Here is the PQRST tool **
P - Precipitating factors (what makes it better or worse?)
Q - Quality (what does it feel like; i.e. sharp, dull, etc.?)
R - Radiating (does it spread anywhere?)
S - Severity (use the pain scale for this)
T - Time (how long does it last? is it intermittent or continuous?)
If you use these standards, you'll almost never go wrong. The focus of these elements is to help track what works, so any modifications can be made to optimize your patient care.