PAIN ASSESSMENT
Pain assessment: should be done with vital signs (q4h) and PRN.
Pain Assessments of the Patient Should Include the Following Information:
• O: Onset of pain
• L: Location of pain
• D: Duration of pain- intermittent or constant, how long has pain been there?
• C: Character of pain (dull, ache, burn, throb, sharp, sore, stab, etc.)
• A: Aggravating factors; Alleviating factors
• R: Radiation/Rating (0-10; mild/medium/severe)
• T: Treatments tried
Objective Information:
• VS
• Wincing; Groaning; Guarding
• Examination findings (surgical site, rebound tenderness etc)
Assessment should bring the abnormal findings from above to a short conclusion.
Plan/Interventions: should include items such as pre-medicating prior to procedures or movement,
repositioning, continued assessment (specific such as Q shift or Q4hr), administration of pain
medications, identifying the patient's goal for pain management (what is his/her acceptable level of
pain), etc.
Evaluate: Follow up with interventions in the following manner:

Non-pharmalogical interventions within one hour

Oral pain medication within one hour

IM pain medication within 30 minutes

IV pain medication within 15 minutes
Documentation: Document pain assessment, interventions & evaluation on 24 hour care
flowsheet. You may also write a progress note at the end of the shift summarizing these and
discussing where patient is at in regards to meeting goal for pain management.