Pain Assessment: Scales, Red Flags and Getting It Right
Pain is one of the most common reasons people seek help, and one of the most commonly undertreated symptoms in healthcare. Assessing it well is a core skill for both paramedic and nursing students, and it is examined in almost every OSCE involving a conscious patient. Good pain assessment does more than produce a number. It helps you find the cause, decide how urgent the situation is, choose the right management and show whether your treatment is working. This guide covers how to take a structured pain history, which scales to use for which patients, and the red flags hiding inside a pain complaint.
Why pain assessment matters
Pain is subjective. Only the patient knows how much it hurts, and two people with the same injury can describe very different experiences. Your job is not to judge whether the pain is real, but to assess it consistently, document it clearly and reassess it after every intervention.
Poorly managed pain is not just unpleasant. It raises the heart rate and blood pressure, increases anxiety, makes assessment harder and can make the patient less able to cooperate with treatment.
A structured pain history
Most services teach a mnemonic. Two of the most common are OPQRST and SOCRATES. Both cover the same ground:
Onset: when did it start, and what were you doing? Sudden onset is more concerning.
Provocation and palliation: what makes it worse or better? Movement, breathing, position or eating?
Quality: what does it feel like? Sharp, dull, crushing, burning, tearing or cramping?
Region and radiation: where is it, and does it spread anywhere?
Severity: how bad is it on a scale?
Time: is it constant or does it come and go? Has it changed?
Associated symptoms: nausea, sweating, shortness of breath, fever, numbness or weakness.
The words a patient uses can point towards a cause. Crushing chest pain suggests cardiac ischaemia. Tearing pain through to the back raises concern for aortic dissection. Colicky pain that comes in waves suggests a hollow organ such as the bowel or ureter.
Choosing the right pain scale
Numerical rating scale
The most widely used tool asks the patient to rate their pain from 0, meaning no pain, to 10, meaning the worst pain imaginable. It is quick, easy to repeat and works for most adults and older children. Research comparing scales has found the numerical rating scale to be practical and reliable in most settings.
Verbal rating scale
Some patients find numbers difficult. Asking them to choose between no pain, mild, moderate and severe is a useful alternative.
Faces scales
Faces scales show a series of faces from happy to very distressed and ask the patient to point to the one that matches how they feel. They are helpful for children who can understand the idea but cannot yet use numbers reliably, and for some patients with language barriers.
Behavioural scales
Some patients cannot tell you about their pain at all. For them, you assess behaviour instead:
The FLACC scale scores Face, Legs, Activity, Cry and Consolability, and is used for young children and those who cannot communicate.
The Abbey Pain Scale is designed for people with advanced dementia and looks at vocalisation, facial expression, body language, behaviour, physiological changes and physical changes.
A patient who cannot tell you they are in pain is not a patient without pain.
Look as well as ask
Watch the patient while you talk to them. Guarding, grimacing, rocking, lying very still, sweating and a raised heart rate all add to your assessment. Remember that some people, particularly older adults and some cultural groups, may underreport pain, while anxiety can make pain feel worse.
Red flags inside a pain complaint
Some pain patterns should immediately raise your level of concern:
Sudden, severe headache that reaches its peak within a minute or so, which may indicate a bleed in the brain.
Tearing chest or back pain, especially with a difference in blood pressure between arms.
Pain out of proportion to the visible injury, which may suggest compartment syndrome, limb ischaemia or a serious infection.
Back pain with leg weakness, numbness in the saddle area, or new bladder or bowel problems.
Abdominal pain in an older patient with a fast heart rate or low blood pressure.
Testicular pain of sudden onset in a young male, which may be torsion.
Managing pain
Pain management combines simple measures with medication given according to your scope and guidelines:
Explain what is happening and reassure the patient, because fear increases pain.
Position the patient for comfort, unless an injury prevents this.
Splint and support suspected fractures.
Use cold packs where appropriate.
Give analgesia according to your clinical practice guidelines and scope of practice.
Always reassess and document the pain score after any intervention. A falling score shows your treatment is working. A score that does not change, or pain that gets worse, needs a rethink.
Documenting pain
Record the score, the scale you used, the time and what you did. Writing "pain 8 out of 10 at 1420, splinted and analgesia given, pain 4 out of 10 at 1435" tells the next clinician exactly what has happened.
Common student mistakes
Asking for a pain score but not the rest of the history.
Using a numerical scale for a patient who clearly cannot use it.
Not reassessing after treatment.
Judging how much pain someone should be in.
Missing the red flags hiding inside the description.
Conclusion
Pain assessment is more than a number from 0 to 10. Take a structured history, choose a scale that suits the patient, watch their behaviour, look out for red flags and reassess after every intervention. Done well, it guides your diagnosis, shows whether your care is working and makes a real difference to how your patient feels.
References
Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073.
Merkel SI, Voepel Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293.
Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1 minute numerical indicator for people with end stage dementia. Int J Palliat Nurs. 2004;10(1):6.
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Disclaimer: This article is general education for students. It is not medical advice, and it does not replace your service's clinical practice guidelines, your educators or your local protocols.
