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Best Practices for Assessing Pain

Nurses recognize their critical ethical and professional responsibilities to assess pain accurately and manage pain effectively. Nurses consistently advocate for optimal pain management for their patients. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patient satisfaction with pain management. HCAHPS ratings directly affect CMS reimbursement as well as the reputation of the healthcare organization. Best Practices for Assessing Pain

McCaffery’s (RN.com, 2010) classic clinical definition of pain indicates that pain is whatever the patient says it is. No objective tests exist to measure pain (American Pain Society, 2009). Whenever possible, clinicians use the patient’s self-report to measure the existence and characteristics of pain (Herr, et al, 2011).

But how do you assess when the patient can’t describe his pain?

Herr, et al (2011) conducted an extensive review of the literature, identified five groups of patients who cannot describe their pain, and selected evidence-based tools which clinicians might employ to assess pain in a patient who cannot express himself fully. They published their work as a position paper, which was adopted by the American Society for Pain Management Nursing. The five groups of patients included older adults with advanced dementia, infants and preverbal toddlers, critically ill/unconscious patients, persons with intellectual disabilities, and patients at the end of life.

Pasero & McCaffrey (2011) developed a Hierarchy of Pain Assessment Techniques, which is recommended for use as a framework to guide assessment approaches in patients unable to self-report. The hierarchy guides healthcare professionals in obtaining a self-report from these patients, identifying potential causes of pain, observing patient behavior to identify the presence of pain, obtaining proxy reports from caregivers and family members, and attempting an analgesic trial in patients unable to self-report pain.

The position paper emphasizes that no single assessment strategy alone is sufficient. Clinicians must use all five of the techniques to the fullest extent possible. A few pearls of wisdom include:

  • Strive to create a means of communicating with the patient if at all possible, (i.e. teaching the patient how to display a certain number of fingers to represent the degree of pain, or how to respond yes/no to questions by grasping your hand or blinking his/her eyes).
  • With critical care patients, delirium may wax and wane. Repeat attempts to communicate.
  • In the sedated, paralyzed, ventilated patient, tearing and diaphoresis represent autonomic responses to discomfort.
  • Sedative and paralytic medications have no analgesic properties.
  • Behavioral assessment tools are not appropriate for patients who are pharmacologically paralyzed or for brain-injured patients.
  • Children aged 8 years and older can use the 1 - 10 scale accurately.
  • Children can express pain at the age of 2 years but may be unable to distinguish pain from other distress.
  • Children who experience chronic pain may not show the same indications of pain that they show in response to acute pain.
  • With older patients who have dementia, nursing assistants and caregivers may be the most accurate sources for pain assessment.
  • Vital signs are not a reliable indicator of pain; however, a sudden change is worth investigating.
  • For intellectually disabled persons, The Faces Pain Tool (Revised) is a self-reporting method for those with suspected mental age greater than 5 years.
  • In any patient, if the pain was a problem before the inability to communicate occurred, investigate and assess for pain.

For a complete discussion of the techniques, patient populations, and assessment tools, please refer to the position paper.


Bette Case Di Leonardi, Ph.D., RN-BC has worked in nursing, education, and healthcare administration for more than 40 years and was among the first group of nurses certified in Nursing Professional Development. Today, Di Leonardi is an independent consultant who publishes and presents on a variety of professional and educational topics.

American Pain Society. American Pain Society (2009). Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: American Pain Society.
Herr, K., Coyne, P., McCaffery, M., Manworren, R., & Merkel, S. (2011). Pain assessment in the patient unable to self-report: Position statement with clinical recommendations. Pain Management Nursing, 12(4), 230 – 250.
Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis: Mosby.
RN.com (2010). Acute and chronic pain: Assessment and management.