Pain Assessment: More Than Asking “Does It Hurt?”

“Does it hurt?” It’s the question we all ask. And it’s a good start — but it’s only the beginning. Pain is the fifth vital sign, yet it’s often treated like an afterthought: tick a box, record a number, move on. Real pain assessment is deeper than that. It’s about listening, noticing, and believing what someone tells you — even when nothing shows up on a scan.

I’ve seen patients quietly pressing their side, wincing as they move, yet answering “I’m fine” when asked directly. I’ve seen people in agony because they’re too polite to complain, too afraid of being labelled difficult, or too used to being told “it’s just part of getting older.” Pain assessment isn’t just about a score — it’s about seeing the person.

This is what proper pain assessment actually looks like — on the ward, in real practice, no textbook shortcuts.

Pain Isn’t Just Sensation — It’s Experience

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Notice what it leads with: experience. Not just injury. Not just nerves. How someone feels about what’s happening to them.

That means two people can have the same injury and feel it completely differently. One might be distressed and overwhelmed; the other might be quiet and withdrawn. Anxiety, tiredness, fear, previous pain experiences, cultural beliefs — all of these change how pain is felt. And they change how someone describes it to you.

If you only ask “how much?” you’ll miss half the picture. You need to know what kind, where, when, what makes it worse — and what it stops them doing.

The Full Assessment — What to Ask

You might remember SOCRATES from lectures. It’s a good framework — but don’t just recite it like a checklist. Listen to the answers. Here’s how to use it in real conversation:

The last part is vital. Someone might say “6 out of 10” — but what does that mean to them? If it stops them sleeping or eating, that’s serious. If it’s “6 but I can still walk and talk,” that’s a different picture. Numbers help track change — they don’t tell the whole story.

Choosing the Right Scale — Not Everyone Uses 0–10

The 0–10 numerical rating scale works well for many people — but not everyone. You need the right tool for the person in front of you:

I’ve seen staff reach for the faces scale simply because someone is elderly. That’s not respectful. If they can tell you a number — ask them. Always offer choice: “Some people find numbers easier, some prefer faces — which works best for you?”

When They Can’t Tell You — Watch, Don’t Just Ask

Confusion, dementia, stroke, learning disability, heavy medication — these can all take away someone’s ability to say “I’m in pain.” That doesn’t mean they aren’t hurting. It means you have to look for the signs instead.

What to Watch For

• Facial expressions — grimacing, frowning, looking tense or withdrawn
• Body language — guarding a part of their body, clutching, restlessness, refusing to move
• Behaviour changes — agitation, shouting, becoming quiet, not eating, disturbed sleep
• Physiological signs — raised pulse or blood pressure, sweating, shallow breathing
• Change in ability — suddenly can’t do things they managed yesterday

Behaviour changes are often dismissed as “just confusion” or “difficult behaviour.” Before you reach for sedation — ask: could this be pain? It’s one of the most common missed causes of distress on the ward.

Believing What You’re Told — Even When It Doesn’t Make Sense

This is the hardest and most important part. Pain doesn’t always have a clear cause. Tests can come back normal. X-rays can be clear. And yet — the pain is real to the person feeling it.

I’ve heard students say “but there’s nothing showing on the scan” — as if that means it’s all in their head. That’s dangerous thinking. Chronic pain, nerve pain, fibromyalgia, functional pain — these are real conditions. They don’t always show up on images. And dismissing them causes more distress than the pain itself.

Some people are stoic. They’ll say “it’s fine” when it’s unbearable. Others express pain loudly and openly. Neither is “right” or “wrong” — they’re just different ways of coping. Meet them where they are.

Red Flags — When Pain Means Act Now

Most pain can be managed step-by-step. But some pain signals something serious. Escalate immediately if you see:

• Sudden, severe pain with no obvious cause — “the worst pain of my life”
• Chest pain — especially radiating to jaw, arm, back, accompanied by breathlessness, sweating, nausea
• Pain in a limb that’s pale, cold, pulseless, or numb
• Back pain with fever, weight loss, or new weakness/numbness in legs — or loss of bladder/bowel control
• Abdominal pain that’s constant, severe, rigid — or where they can’t bear to be touched
• Pain that’s getting rapidly worse despite medication

Recording It Properly — So Everyone Knows

A score on its own tells the next nurse very little. Write down: what they told you, what you observed, what was done, and — crucially — whether it changed after treatment.

Good note: “Patient reports sharp right-sided chest pain, 7/10, worse on breathing in. Observations stable. GP prescribed oral analgesia — given at 14:00. Reassessed 15:00 — now 4/10, able to take deep breath. Will continue to monitor.”

When handing over: don’t just say “pain managed.” Say “they’re still getting abdominal pain at night — it wakes them up — please review overnight analgesia.” That’s what needs to be passed on.

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