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  • Chance Reaves

How Nurses Should Document Pain

Updated: Aug 10

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