NCLEX Review Guide: Nursing Process & Documentation - Pain Assessment

Five-Step Nursing Process

1. Assessment: Systematic data collection about patient's health status
2. Diagnosis: Analysis of assessment data to identify nursing problems
3. Planning: Development of patient-centered goals and interventions
4. Implementation: Execution of planned nursing interventions
5. Evaluation: Assessment of goal achievement and plan effectiveness

Pain as the Fifth Vital Sign

• Pain is a subjective experience that must be assessed regularly alongside traditional vital signs
• Patient's self-report is the gold standard for pain assessment - believe what the patient tells you
• Pain assessment should occur at admission, with vital signs, before/after interventions, and when patient reports pain

PQRST Pain Assessment Method

• Provocation/Palliation: What makes it better or worse?
• Quality: Describe the pain (sharp, dull, burning, cramping)
• Region/Radiation: Where is it located? Does it spread?
• Severity: Rate on 0-10 scale
• Timing: When did it start? Constant or intermittent?

Appropriate Pain Scales by Population

Documentation Requirements

• Document pain assessment using facility-approved scales and methods
• Include location, intensity, quality, duration, and aggravating/alleviating factors
• Record interventions provided and patient response within 30-60 minutes
• Use objective, factual language avoiding personal interpretations

What NOT to Document

• Avoid: "Patient appears comfortable" when they report pain
• Avoid: "Patient seems to be drug-seeking"
• Avoid: Personal opinions about patient's pain level
• Avoid: Assumptions about pain based on diagnosis alone