Pain Assessment

Objective Assessment

It is always important to perform an objective assessment following a subjective assessment, but this is particularly the case for infants, young children, and non-verbal clients who may have difficulties with self-reporting.

The type of objective assessment used will depend on the location of the pain, the related body systems, and the acuity of the situation. Specific focused assessments on a body system may be necessary. For example, if a client describes knee pain, you should do a focused assessment on the musculoskeletal system. If a client describes chest pain, you should do a focused assessment on the cardiovascular and the respiratory system and possibly the musculoskeletal system.

The objective assessment does not follow a specific order; it depends on the acuity of the situation and the stability of the client. Common components of an objective assessment of pain include:

  • Full set of vital signs.
    Vital signs can be affected by pain, particularly acute pain. Collection and assessment of vital sign data may provide important information related to the client’s stability and the potential for clinical deterioration. Vital signs are also an important component of pain tools that include physiological measures; these can be particularly helpful in clients who are pre-verbal or non-verbal such as newborns, young children, clients that may have a developmental challenge, and clients who are unconscious. However, vital sign changes cannot help you differentiate between pain and other forms of distress such as fear and anxiety. You should always consider the context when interpreting vital signs, because they can be affected by level of consciousness, medications, and sedation. Therefore, your clinical judgement will be based on a comprehensive subjective and objective assessment, along with critical thinking.
  • Inspection of the area.
    Typically, you will inspect the area on the body where a client indicates they are having pain. Inspection is performed bilaterally in which you compare the left side to the right side. For example, if a client is having eye pain, you should compare the left eye to the right eye. Inspect for and note any abnormalities such as discoloration (e.g., redness), bruising, swelling, scarring, incisions, masses, deformities, asymmetry, lesions, non-intact skin, and pressure injuries. With chest pain, you should also inspect for cardiac heaves (forceful movements observed on the skin over the chest wall) and epigastric pulsations. With abdominal pain, you should also inspect for abdominal contour and peristaltic movements.
  • Palpation of the area.
    After conducting a subjective assessment, you should palpate the area (and related areas) in which the client is having pain. Palpation is performed bilaterally: compare the left side to the right side. For example, if a client is having left shoulder pain, you should palpate the right shoulder first and then the painful left shoulder. Similarly, if a client is having abdominal pain, you should palpate the painful area last. During palpation, you should assess skin temperature, swelling, masses, deformities, and if associated with a joint. You should also observe any signs of pain during palpation, such as a change in respiration (e.g., holding their breath), facial grimacing, withdrawing their body/limb, and guarding.
  • Auscultation and percussion.
    Perform auscultation and percussion when a client is describing chest or abdominal pain. For example, with chest pain, you should auscultate the lungs, and the apical pulse and cardiac valves. With abdominal pain, you should auscultate the abdomen for bowel sounds and percuss the abdominal area.

Clinical Tip

Always compare the right and left side of the body when inspecting and palpating, because the best standard of comparison is the client’s own anatomy. The presence of a bilateral versus a unilateral finding is often of clinical significance. For example, the left ankle should be symmetrical with the right ankle. The presence of edema in one ankle versus both ankles is meaningful when making judgements about the underlying pathology.

When palpating an area, be aware of responses that may be categorized as allodynia or hyperalgesia. For example, if you press gently on an area (a stimulus that does not normally result in pain) and the client communicates pain, this is considered allodynia. Additionally, if you press firmly on an area (a stimulus that would normally result in pain) and the client communicates an exaggerated response to the pain, this is considered hyperalgesia. These conditions are different, but may coexist in the presence of diseases such as migraines and diabetes.