Pain Assessment

Pain Assessment

You have an important role to play in screening for and assessing pain (RNAO, 2013).

You will often be the first person to recognize that a client is in pain as a result of your assessment including observations. Nurses also spend sustained periods of time with clients, so clients are more likely to share this information with you than with other healthcare professionals. If they say they are in pain, believe them. Trust will disintegrate if clients feel you do not believe them.

Unassessed pain can lead to inadequate pain management and/or untreated pain. This is a serious problem because it can affect many body systems as well as a client’s cognitive capacity and quality of life, and even whether they live or die. 

Pain can be difficult to assess because it is a personal experience that affects clients in different ways. Clients may also have difficulty articulating their pain and describing what it feels like. Sometimes pain is invisible, making it difficult to recognize, particularly in someone with chronic pain. The next sections explore the dimensions of pain so that you can develop an understanding of how pain may appear.

Dimensions of Pain Assessment

Pain has many dimensions in terms of how it affects a person (see Table 1). The various dimensions of pain can involve various descriptions and considerations (Cleeland, 2009). It is important to be aware that these dimensions are not necessarily separate; for example, the subjective dimension includes cognitive, psychological, and social features. Consider the many dimensions in terms of your pain assessment of the client and which pain assessment tools may be best in certain situations and populations (this will be discussed in more detail later).

Table 1: Dimensions of pain and related considerations.







A report of pain by the person who is experiencing it is important because they know their pain best and how to describe it. This is sometimes referred to as the sensory dimension of pain, which includes a client communicating the intensity of pain and other descriptors. 


  • A subjective assessment of pain is often referred to as a self-report. This commonly includes a verbal self-report, but also can involve pointing or a written self-report.
  • Subjective description of pain is only one way to express pain, and inability to communicate by no means indicates that a person is not experiencing pain (International Association for the Study of Pain, 2020). 


Common physiological responses from pain may include tensing of muscles, pupil dilation, dry mouth, and a change in vital signs. 


  • With acute pain, physiological responses can be important to consider, particularly with certain populations who are pre-verbal or non-verbal.
  • However, it is important to note that vital signs cannot discriminate between pain and other states of distress such as fear. Additionally, underlying disease processes and medications such as sedation can affect vital signs.


Behaviours associated with pain can include facial and bodily responses such as grimacing, moaning, crying, fidgeting, guarding, and laying still. Other behaviours associated with pain include change in sleep patterns and eating patterns.


  • Behavioural dimensions of pain vary widely among clients. Don’t assume someone isn’t in pain if they are not demonstrating any of these behaviours. The presence of these behaviours may be more apparent with acute versus chronic pain.
  • Some responses are based on developmental stages and cultural influences. For example, a common behavioural response to pain among infants is grimacing and crying. Another consideration is related to culture and gender. For example, when young boys experience pain, parents often respond by saying “don’t cry, be a big boy.” Among individuals identifying as male, this can lead to more inhibited expressions of pain. Additionally, people with physical disabilities may exhibit pain behaviours in different ways. 


Pain can affect a person’s cognitive functioning in terms of their ability to think, reason, acquire and remember knowledge, attention span, and learning. 


  • Cognitive dimensions of pain will vary based on a client’s developmental stage.
  • Effects of pain on cognition can be assessed based on self-reports and empirical tests.

Psychological and social

Clients may become anxious, irritable and upset, or have a flat affect (lack of reaction on the face). Chronic pain can affect a client’s identity and social relationships and can lead to social withdrawal and depression.


  • It is important to assess a client’s psychological and social response to pain. This can help you understand how pain affects them, their coping strategies, and priorities of care. For example, depression is a serious issue that can affect overall health and well-being.


This dimension refers to the ways that pain interferes with daily functioning (Cleeland, 2009). 


  • Reactive dimensions are important to assess in order to understand interference with activities such as walking, sleep, relationships, and mood (Cleeland, 2009).

Contextualizing Inclusivity

Sex and gender biases and discrimination pervade every aspect of social life, including pain assessment in healthcare. In one study, individuals were shown video clips of female and male faces expressing pain. The authors concluded that females tend to be perceived as in less pain than men (Zhang et al., 2021). This experiment did not involve healthcare professionals, but this kind of gender bias can pervade all settings including healthcare. A systematic review revealed that healthcare providers do not take women’s pain as seriously as men’s pain and often psychologized women’s pain (“it’s all in her head”) (Samulowitz et al., 2018). Gender bias influences perceptions of women being more sensitive and emotional to pain and also influences treatment options (Laitner et al., 2021; Samulowitz et al., 2018). For example, healthcare providers are more likely to recommend surgical interventions for men than women (Laitner et al., 2021). Women are also less likely to be prescribed opioids as pain medications and are more likely to be prescribed antidepressants and to be given mental health referrals for pain compared to men (Samulowitz et al., 2018).

Activity: Check Your Understanding


Association for the Study of Pain (2020). IASP announces revised definition of pain.

Cleeland, C. (2009). The Brief Pain Inventory: User guide.

Laitner, M., Erikson, L., Society for Women’s Health Research Osteoarthritis and Chronic Pain Working Group, & Ortman, E. (2021). Understanding the impact of sex and gender in osteoarthritis: Assessing research gaps and unmet needs. Journal of Women’s Health, 30(5).

RNAO (2013). Assessment and management of pain. 3rd edition.

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research and Management, article ID 6358624.

Zhang, L., Losin, E., Ashar, Y., Koban, L., & Wager, T. (2021). Gender bias in estimation of others’ pain. The Journal of Pain, 22(9), 1048-1059.


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