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Tools for Assessment of Pain in Adults Pain 

SAMPLE 5 – Pain Assessment Tool

Assessment Date:_____________
Name:____________

Location of Pain: Use letters to indentify different pains.

(Illustrated by: Nancy A. Bauer, Hon BA, B. Comm, RN, CETN)

Intensity: Use appropriate pain tool to rate pain subjectively/objectively on a scale of 0-10.

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Location	Pain A	Pain B	Other
What is your/their present level of pain?
What makes the pain better?
What is the rate when the pain is at it's least?
What makes the pain worse?
What is the rate when the pain is at it's worst?
Is the pain continuous or intermittent (come & go)?
When did this pain start?
What do you think is the cause of this pain?
What level of pain are you satisfied with?

Quality: Indicate the words that describe the pain using the letter of the pain (A,B,C) being described.

•   Aching
•   throbbing
•   shooting
•   stabbing
•   gnawing
•   sharp
•   burning
•   tender
•   exhausting
•   tiring
•   penetrating
•   numb
•   nagging
•   hammering
•   miserable
•   unbearable
•   tingling
•   stretching
•   pulling
• Other:_____________

Originally adapted with permission from Grey Bruce Palliative Care/Hospice Association Manual. Reprinted with Permission. Brignell, A. (ed) (2000). Guideline for developing a pain management program. A resource guide for long-term care facilities, 3rd edition.

Effects of pain on activities of daily living	Yes	No	Comments
sleep and rest
social activities
appetite
physical activity and mobility
emotions
sexuality/intimacy

Effects of Pain on your Quality of Life: (happiness, contentment, fulfillment) What can't you do that you would like to do or what activity would improve the resident's quality of life?
_______________________________________________

Current Medications and Usage:
_______________________________________________

Family Support:
_______________________________________________

Symptoms: What other symptoms are you/they experiencing?

•   constipation
•   nausea
•   vomiting
•   fatigue
•   insomnia
•   depression
•   short of breath
•   sore mouth
•   weakness
•   drowsy
• Other: ___________

Behaviours: What behaviours are you/they experiencing?

•   calling out
•   restless
•   resistant to movement
•   not eating
•   pacing
•   not sleeping
•   withdrawn
•   noisy breathing
•   rocking
• Other: ___________

Have you experienced a significant degree of pain in the past? How did you manage that pain?
______________________________________________________________

Is there anything else you can tell us that will enable us to work with you in managing your pain?
______________________________________________________________

Nursing Pain Diagnosis:

•   nociceptive
•   visceral
•   neuropathic
•   suffering
•   incident pain
•   somatic
•   muscle spasm
•   raised intracranial pressure

Problem List: (resident care plan))

1. ______________________
2. ______________________
3. ______________________
4. ______________________

Signature:____________
Date:_____________

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