Pain is one of the most common reasons people seek care, and one of the most commonly under-treated. Untreated pain slows recovery, prevents deep breathing and mobility, disturbs sleep, increases delirium, and causes needless suffering. Good pain management starts with good assessment, and nurses do most of it.
Principle 1: pain is what the patient says it is
Self-report is the gold standard. Don’t judge pain by facial expression or vital signs alone, and don’t assume people from some cultures, or people who are calm, feel less pain. Biases in pain assessment affect women, Black patients, older people and people with sickle cell disease, among others.
A full pain assessment (SOCRATES)
- Site: where is it?
- Onset: when did it start; sudden or gradual?
- Character: sharp, dull, burning, cramping?
- Radiation: does it spread?
- Associations: nausea, sweating, breathlessness?
- Time course: constant or comes and goes?
- Exacerbating and relieving factors.
- Severity: using a scale.
Tools for adults who can communicate
- Numeric Rating Scale (NRS): “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, what is your pain now?”
- Verbal Rating Scale: none, mild, moderate, severe.
- Assess pain at rest and on movement (e.g. deep breathing, coughing, turning), especially after surgery.
Tools for children
| Tool | Age | How it works |
|---|---|---|
| FLACC | 2 months to 7 years, or non-verbal children | Observer scores Face, Legs, Activity, Cry, Consolability (0–2 each, total 0–10) |
| Wong-Baker FACES | About 3 years and older | Child points to the face that matches how they feel |
| Faces Pain Scale – Revised | About 4–12 years | Six faces scored 0–10 |
| Numeric scale | About 8 years and older | As for adults |
Involve parents: they know their child’s usual behaviour. For newborns, neonatal tools such as the NIPS or PIPP are used in neonatal units.
People with dementia or who can’t speak
Use observational tools such as PAINAD (Pain Assessment in Advanced Dementia), which scores breathing, negative vocalisation, facial expression, body language and consolability, or the Abbey Pain Scale. Look for changes in behaviour: agitation, withdrawal, refusing food, guarding, crying out during care. In intubated ICU patients, tools such as the CPOT or BPS are used.
Treating pain: the WHO approach
WHO’s analgesic “ladder”, originally designed for cancer pain, remains a useful way to think about matching treatment to severity:
- Mild pain: non-opioids (paracetamol, NSAIDs), with or without adjuvants.
- Moderate pain: add a weak opioid or a low dose of a strong opioid.
- Severe pain: strong opioids (e.g. morphine), with non-opioids and adjuvants.
Give analgesia regularly (“by the clock”) for ongoing pain, not just when it becomes severe. Use non-drug measures too: positioning, heat or cold where appropriate, distraction, reassurance, and explanation.
Reassess and document
- Reassess after giving analgesia: commonly 30–60 minutes after oral and 15–30 minutes after IV, as per policy.
- Record the score, intervention and effect.
- With opioids, also assess sedation and respiratory rate.
- Escalate if pain is not controlled. Sudden severe or changing pain can signal a complication.
Related: Sickle cell crisis pain management · Palliative care · Post-operative care
Based on WHO guidance on pain management, the FLACC, Wong-Baker FACES and PAINAD tools, and standard pain assessment practice. Educational content: follow your local pain policy.