Nursing Fundamentals: Pain Assessment, Comfort Measures, and Reassessment

Why Pain Assessment Matters in Bedside Care

Pain is whatever the patient says it is, and it can change quickly. Effective pain care starts with a structured assessment, followed by targeted comfort measures, then timely reassessment. Your goal as a beginner nurse is to (1) measure pain consistently, (2) reduce suffering safely, (3) monitor for problems, and (4) communicate changes that require escalation.

Assessment Framework: A Consistent Pain Interview

Core Components to Assess Every Time

• Location: “Where is the pain? Does it move anywhere?” Ask the patient to point with one finger if possible.
• Quality: “How would you describe it?” (sharp, dull, burning, throbbing, cramping, pressure, stabbing).
• Intensity: Use a validated scale (see below) and record the score.
• Timing: Onset, duration, pattern (constant vs intermittent), and whether it is getting better/worse.
• Aggravating/relieving factors: Movement, coughing, eating, position changes, heat/cold, rest, splinting, medications already tried.
• Functional impact: What the pain prevents (deep breathing, walking, sleep, eating, therapy participation, self-care). Functional impact helps set realistic goals.

Step-by-Step: A Beginner-Friendly Script

1. Start with intensity and location: “On a 0–10 scale, what is your pain right now? Where is it?”
2. Clarify quality and timing: “What does it feel like? When did it start? Is it constant or does it come and go?”
3. Identify triggers and relievers: “What makes it worse? What helps even a little?”
4. Assess function: “What are you unable to do because of the pain?”
5. Set a comfort goal: “What pain level would feel manageable so you can rest or move?”

Validated Pain Scales: Choosing the Right Tool

Numeric Rating Scale (NRS) 0–10

Best for patients who can self-report with numbers. Confirm what “10” means to the patient (worst imaginable for them). Document the number and context (at rest vs with movement).

Faces Scale

Useful for children and adults who prefer visual options. Ask the patient to choose the face that matches how they feel. Document the selected face/score per facility tool.

Behavioral Indicators (When Self-Report Is Not Possible)

For nonverbal or cognitively impaired patients, use an approved behavioral pain tool per your facility (often includes facial expression, body movements, muscle tension, ventilator compliance/vocalization, and consolability). Also consider physiologic cues (tachycardia, hypertension, diaphoresis) as supportive data, not a replacement for a validated tool.

Special Considerations

Older Adults

• Do not assume pain is “normal aging.” Ask directly and routinely.
• Assess function carefully: pain may show up as decreased mobility, poor sleep, reduced appetite, agitation, or withdrawal.
• Higher risk with sedating medications: monitor for increased sleepiness, confusion, falls risk, and slowed breathing after pharmacologic interventions (coordinate with RN/provider orders and facility policy).

Nonverbal Patients

• Look for change from baseline: grimacing, guarding, resisting care, moaning, restlessness, rigid posture, pulling at lines, increased ventilator dyssynchrony.
• Use family/caregiver input: “What does discomfort look like for them?”
• Trial comfort measures and reassess with the same behavioral tool to evaluate response.

Cultural Differences and Individual Meaning of Pain

• Expression varies: some patients minimize pain; others are more expressive. Avoid judging credibility based on appearance.
• Ask preferences: “What usually helps when you hurt?” “Are there practices we should know about?”
• Use professional interpreters when language barriers exist to avoid errors in assessment and safety instructions.

Opioid Safety Awareness (Without Dosing)

When pharmacologic options include opioids, bedside safety focuses on observation and timely reporting. Key risks include excessive sedation and respiratory depression. Know your facility’s sedation scale and monitoring expectations.

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• Red flags to report promptly: difficult to arouse, new confusion, slurred speech, very slow or shallow breathing, oxygen saturation decline, repeated “nodding off,” pinpoint pupils with decreased responsiveness.
• Common side effects to monitor: nausea, constipation, itching, dizziness, urinary retention (report and support per orders).
• Safety basics: assist with ambulation, ensure call light access, and reinforce that the patient should request help before getting up if drowsy.

Comfort-Care Toolkit: Nonpharmacologic Interventions

Comfort measures can reduce pain intensity, improve function, and support pharmacologic therapy. Choose interventions based on the pain type, patient preference, and contraindications.

Positioning and Support

1. Assess current posture: look for guarding, tension, pressure points, and line/tube pulling.
2. Reposition with purpose: align joints, support the painful area, and reduce strain (pillows, rolled blankets, wedges).
3. Protect skin and devices: check that oxygen tubing, drains, and IV lines are not kinked or pulling.
4. Reassess pain and function: ask about pain at rest and with movement after repositioning.

Examples: elevate an edematous limb (if ordered/appropriate), support an incision during coughing, place a pillow between knees for hip/back discomfort, or adjust head-of-bed to ease breathing-related discomfort.

Heat and Cold: Safety Checks First

Heat can relax muscles and improve comfort; cold can reduce swelling and numb localized pain. Always follow facility policy and provider orders when required.

• Before applying: assess skin integrity, sensation, circulation, and patient’s ability to report discomfort. Avoid extremes in patients with impaired sensation or poor perfusion.
• Protect the skin: use a barrier (cloth cover), never place directly on skin unless the product is designed for it.
• Time awareness: use short intervals and frequent skin checks; stop if skin becomes very red, pale, blistered, or the patient reports burning/numbness beyond expected.
• Avoid/Use caution: over areas with decreased sensation, open wounds (unless specifically ordered), active bleeding, severe peripheral vascular disease, or immediately post-op if contraindicated.

Relaxation Breathing (Quick Bedside Coaching)

1. Set the scene: reduce noise if possible; ask the patient to place one hand on the abdomen.
2. Inhale slowly through the nose for a comfortable count (e.g., 3–4), feeling the abdomen rise.
3. Exhale longer than inhale through pursed lips (e.g., 4–6), letting shoulders drop.
4. Repeat 5–10 cycles, then reassess pain and tension.

This is especially helpful for anxiety-amplified pain, dyspnea-related discomfort, and during painful movement (e.g., repositioning).

Distraction and Attention Shifting

• Options: conversation, music, guided imagery, TV, simple games, phone calls with family, or focusing on a task (counting breaths).
• When to use: during dressing changes (if allowed), mobility, waiting for medication onset, or chronic pain flares.
• Tip: match the method to the patient’s interests; forced distraction can increase distress.

Environmental Modifications

• Reduce triggers: dim harsh lights, lower noise, cluster care when feasible, and ensure comfortable room temperature.
• Promote rest: offer eye mask/earplugs if available, adjust alarms appropriately per policy, and support sleep routines.
• Basic needs: offer toileting, hydration (if allowed), oral care, and warm blankets—unmet needs can amplify pain.

Coordinate With the Care Team for Pharmacologic Options

Nonpharmacologic measures do not replace needed medications. Communicate clearly when pain remains uncontrolled or limits essential activities (deep breathing, mobility, therapy). Provide actionable information: current pain score, functional limitation, what has been tried, and response.

Reassessment: Timing and What to Look For

When to Reassess

• After any intervention (repositioning, heat/cold, breathing coaching, medication administration per facility expectations).
• After activity that may increase pain (ambulation, therapy, coughing, wound care).
• When the patient reports a change or you observe new behaviors (restlessness, guarding, grimacing).

Follow your unit policy for reassessment intervals; if none is specified, reassess soon enough to capture the expected onset of the intervention and to ensure safety monitoring.

What to Reassess and Document

• Pain score using the same scale as baseline.
• Location/quality changes (new radiation, new pressure, new burning).
• Functional response: can the patient take deep breaths, turn, walk, sleep, participate in therapy?
• Side effects/safety: increased sedation, dizziness, nausea, itching; and respiratory depression awareness (slow/shallow breathing, decreased alertness).
• Objective observations: guarding, facial tension, ability to relax, vital sign trends if relevant to the situation (without re-teaching vital sign technique).

Documentation Expectations (Practical Checklist)

• Baseline assessment: scale used, score, location, quality, timing, aggravating/relieving factors, functional impact, patient-stated comfort goal.
• Interventions: what you did (e.g., repositioned to left side with pillow support; coached pursed-lip breathing; applied cold pack with barrier and skin checks; reduced environmental stimuli).
• Pharmacologic coordination: medication given per order (name/route per MAR if applicable) and patient education provided (e.g., splinting, calling for help if drowsy).
• Reassessment: time, new pain score, functional change, side effects, and whether additional action was needed.
• Escalation: who was notified, what was reported, and any new orders or instructions received.

Escalation Criteria: When Pain Signals an Emergency

Some pain patterns require immediate escalation rather than routine comfort measures.

• Sudden, severe pain that is new or rapidly worsening, especially with pallor, diaphoresis, weakness, confusion, or hypotension.
• Chest pain descriptors: pressure, squeezing, heaviness, tightness, pain radiating to jaw/arm/back, or associated shortness of breath, nausea, or sweating.
• New neurologic symptoms with pain: weakness, numbness, difficulty speaking, severe headache with sudden onset.
• Post-op red flags: pain out of proportion to expected course, new swelling/tightness, increasing firmness, or uncontrolled pain despite interventions.
• Opioid safety red flags: difficult to arouse, markedly slowed breathing, or declining oxygenation with increased sedation.

Structured Practice Scenarios

Scenario 1: Post-Op Abdominal Pain With Splinting Education

Situation: A patient is 6 hours post-op with an abdominal incision. They report pain 8/10 when coughing and refuse to use the incentive spirometer because it “hurts too much.”

Assessment (use the framework):

• Location: incision area; no new radiation.
• Quality: sharp with movement/cough.
• Intensity: 3/10 at rest, 8/10 with coughing.
• Timing: worse with position changes and deep breathing.
• Aggravating/relieving: worse with cough; slightly better when still.
• Functional impact: avoiding deep breathing and mobility.

Interventions (step-by-step):

1. Position: elevate head-of-bed slightly and support knees to reduce abdominal tension.
2. Teach splinting: place a folded pillow or blanket over the incision; instruct the patient to hold it firmly against the incision before coughing, deep breathing, or moving.
3. Coach breathing: slow inhale through nose, longer exhale through pursed lips; practice 5 cycles before coughing.
4. Coordinate care: if medication is ordered and due, time mobility/IS practice for when pain control is expected to be improved; communicate functional limitation to the RN/provider as needed.
5. Encourage graded activity: short, frequent attempts at deep breathing/IS rather than long sessions.

Reassessment: document pain at rest and with coughing after splinting and breathing coaching; note whether the patient can perform IS and turn in bed. Monitor for sedation/respiratory concerns if medications were administered.

Example documentation snippet:

1400 Pain 3/10 at rest, 8/10 with cough; sharp at incision; limits IS use. Repositioned HOB 30°, pillow under knees. Taught incision splinting with folded blanket and coached pursed-lip breathing x 8 cycles. 1415 Reassess: pain 3/10 at rest, 6/10 with cough; patient able to cough with splint and completed IS x 5 breaths. No increased sedation noted; respirations even/unlabored.

Scenario 2: Chronic Pain With Functional Goals

Situation: A patient with chronic low back pain reports “always a 7/10,” requests to stay in bed, and declines physical therapy.

Assessment focus:

• Clarify baseline: “Is 7/10 typical for you? What is a good day like?”
• Quality: aching vs burning/shooting (may suggest neuropathic features to report).
• Timing/pattern: morning stiffness, activity-related flares.
• Functional impact: walking distance, ability to sit, sleep quality.
• Patient goal: shift from “zero pain” to “able to walk to bathroom with tolerable pain.”

Interventions (step-by-step):

1. Set a functional goal: “Let’s aim for pain that allows you to sit up for meals and walk to the bathroom safely.”
2. Positioning plan: neutral spine support with pillows; avoid prolonged one position—offer scheduled micro-repositioning.
3. Heat/cold safety: if appropriate and allowed, trial one method with skin checks and short intervals; document response.
4. Relaxation + pacing: brief breathing practice before movement; encourage short, frequent walks rather than one long session.
5. Distraction: music or guided imagery during mobility or while waiting for therapies.
6. Coordinate: communicate to PT/OT and RN that the patient’s barrier is pain and fear of worsening; request timing of therapy when comfort is optimized per orders.

Reassessment: measure pain score and, importantly, function (tolerated sitting, stood with assistance, walked X feet). Document what improved and what still limits activity.