Clinical pain assessment • Adults • Children • Emergency triage • Palliative care

Clinical Assessment of Pain in Adults and Children

A structured, age-appropriate approach for emergency medicine and palliative-care practice

Learning objectives

• Perform a rapid first look and identify pain-related emergencies.
• Take a complete pain history using SOCRATES/OPQRST while incorporating function, goals and total pain.
• Combine self-report, caregiver report, behaviour, examination and investigations without allowing a score to replace clinical reasoning.
• Select and correctly use age- and developmentally appropriate pain scales for adults, children, neonates and people who cannot self-report.
• Recognize how developmental, physiological, psychological, social and cultural factors affect assessment.
• Document and communicate a pain assessment so another clinician can safely act on it.

1. The central principle: believe, assess, explain and reassess

Pain is subjective and the patient’s report is the primary source whenever the patient can communicate reliably. A normal pulse, a calm face or a normal scan does not disprove pain. Conversely, a high score is not a diagnosis. Good assessment describes the pain, searches for its cause and mechanism, measures its effect on function and identifies urgent risks.

2. Rapid first look and emergency triage

Before detailed questioning, observe the patient while approaching: posture, work of breathing, skin colour, sweating, consciousness, movement, guarding, distress and the caregiver’s concern. Use a structured primary survey.

Primary survey	Pain-related questions and actions
Airway	Can the patient speak? Is facial, neck or oral pain threatening the airway? Look for swelling, burns, bleeding, secretions or reduced consciousness.
Breathing	Respiratory rate, oxygen saturation, effort, chest movement and pain on breathing. Treat hypoxia or severe distress immediately.
Circulation	Pulse, blood pressure, capillary refill, skin temperature, bleeding and shock. Severe pain with shock is an emergency, not simply a high score.
Disability	Level of consciousness, pupils, glucose, new weakness, sensory loss, seizure, confusion and medication effects.
Exposure	Inspect the painful area, skin, wounds, swelling, deformity, pressure injury, rash, abdominal distension and signs of infection while preserving dignity and warmth.

3. Pain history: SOCRATES in full

The supplied Makerere University reference emphasizes SOCRATES. OPQRST is a useful equivalent. Use the mnemonic as a memory aid, not a rigid interrogation; start with the patient’s story and follow clinical clues.

Letter	Domain	Questions and examples
S	Site	“Where is the pain?” Ask the patient to point with one finger. Is it superficial, deep, diffuse or at several sites? Use a body map and mark radiation.
O	Onset	When did it begin? Sudden or gradual? What was happening? Injury, meal, exertion, procedure, medication change, infection or no obvious trigger?
C	Character	Words such as sharp, burning, electric, aching, cramping, pressure, tearing, itching or throbbing. Ask the patient’s own words before offering examples.
R	Radiation/region	Does it travel to the arm, jaw, shoulder, back, groin or another area? Is the distribution dermatomal, joint-based, visceral or widespread?
A	Associations/aggravating and relieving factors	Fever, vomiting, breathlessness, sweating, weakness, numbness, bowel/bladder change, rash, bleeding, sleep or mood change. What worsens or relieves it—movement, food, position, touch, heat, rest, medicines?
T	Timing and time course	Continuous or intermittent? Constant baseline with flares? Duration of each episode, frequency, night pain, end-of-dose or incident pain? Is it improving, stable or worsening?
E	Exacerbating/relieving factors and effect	What can the patient no longer do? Walking, breathing deeply, feeding, sleeping, working, praying or caring for children? What is the patient’s acceptable goal?
S	Severity	Use a validated age-appropriate scale, record current pain, usual/best/worst pain, pain at rest and movement, and the functional goal.

High-yield follow-up questions

• “What do you think is causing this pain?” and “What are you most worried it could mean?”
• “Have you had this pain before? What diagnosis or treatment helped?”
• “What medicines, herbs, alcohol or recreational drugs have you used, and when was the last dose?”
• “Do you have allergies, kidney or liver disease, ulcers, pregnancy, bleeding problems or a history of falls?”
• “How has the pain affected sleep, appetite, breathing, mobility, mood and relationships?”
• “Who helps you at home, and can they obtain and administer treatment safely?”

4. Quantitative pain measurement

A scale creates a common language and allows trend monitoring. It does not diagnose the cause, measure tissue damage or determine a dose by itself. Use the same scale consistently, explain its anchors and document the context.

Tool	How it works	Best use and limits
Numeric Rating Scale (NRS)	Usually 0–10: 0 = no pain, 10 = worst imaginable pain.	Adults and older children who understand numbers. Clarify whether “10” means worst imaginable or worst experienced.
Verbal Descriptor Scale	No pain, mild, moderate, severe or another locally validated set of words.	Useful when numbers are confusing or language is more comfortable than arithmetic.
Visual Analogue Scale (VAS)	A line anchored by no pain and worst pain; the patient marks a point.	Requires vision, motor control and abstract understanding; less useful in acute distress or very young children.
Wong–Baker FACES	A sequence of facial expressions linked to increasing pain intensity; the child selects the face matching their own pain, not how they look.	Often useful from about 3 years when developmentally appropriate; explain that faces show how much it hurts.
FLACC	Face, Legs, Activity, Cry and Consolability, each scored 0–2.	Young, preverbal or cognitively impaired children; observe at rest and during an appropriate care activity.
NIPS	Neonatal Infant Pain Scale using facial expression, cry, breathing pattern, arms, legs and arousal.	Neonates; use with gestational age, clinical context and repeated assessment.
CRIES	Crying, oxygen requirement, vital-sign increase, facial expression and sleeplessness.	Postoperative neonates in settings using the validated tool.
PAINAD	Breathing, negative vocalization, facial expression, body language and consolability.	People with advanced dementia who cannot reliably self-report; establish baseline behaviour.
CPOT or behavioural ICU tools	Observes facial expression, body movement, muscle tension and ventilator compliance or vocalization.	Critically ill, intubated or non-communicative adults; follow local validation and training.

Best practice: record the tool and score, for example “NRS 7/10 at rest, 9/10 on movement, right iliac fossa, 4 hours after last analgesic.” A score without site, time, context and function is not reproducible.

5. Qualitative and biopsychosocial assessment

Physical and functional domains

• Location, mechanism, disease cause, trauma, procedures, treatment toxicity and comorbidities.
• Sleep, appetite, hydration, mobility, breathing, bowel and bladder function, sexual function and ability to perform daily activities.
• Current medicines, adherence, effectiveness, adverse effects, duplicate products, allergies, interactions, renal/hepatic function and substance use.

Psychological domains

• Fear, anxiety, depression, anger, trauma, catastrophizing, hopelessness, suicidal thoughts and perceived control.
• Past experiences with pain, hospitals, opioids or discrimination; expectations and preferred coping methods.

Social and spiritual domains

• Family response, caregiver availability, work, school, transport, food, safe housing, cost and access to medicines.
• Beliefs about illness, traditional or spiritual practices, meaning, guilt, hope and preferred decision-makers.

Patient priorities

Ask, “What would you like to be able to do if the pain were better?” Goals may be breathing comfortably, walking to the toilet, sleeping, feeding a baby, attending worship or spending time with family—not necessarily a zero score.

6. Physical examination

Explain the examination, obtain permission, provide a chaperone where appropriate and compare both sides. Examine gently; a painful examination can worsen fear and guarding.

1. General: posture, distress, pallor, sweating, fever, cachexia, hydration, level of alertness and mobility.
2. Vital signs: respiratory rate, oxygen saturation, pulse, blood pressure, temperature and glucose when indicated. Abnormal signs support urgency but normal signs do not exclude pain.
3. Inspection: wounds, swelling, deformity, bruising, rash, erythema, pressure injury, surgical sites, distension and muscle wasting.
4. Palpation: tenderness, guarding, rebound where clinically justified, masses, crepitus, warmth, fluctuance, pulses and compartment tension.
5. Neurological examination: sensation, allodynia, pinprick/light touch as appropriate, strength, tone, reflexes, gait, cranial signs and autonomic changes.
6. Musculoskeletal examination: range of motion, joint stability, spine, limb alignment and pain with active versus passive movement.
7. System examination: cardiovascular, respiratory, abdominal, genitourinary and skin examination guided by symptoms and red flags.

7. Physiological signs: useful clues, poor substitutes

Acute pain may increase respiratory rate, heart rate, blood pressure, muscle tension, sweating, pupil size and blood glucose through sympathetic activation. Children may cry, withdraw, become still or resist care. Chronic pain, shock, beta-blockers, autonomic neuropathy, sedation, hypothermia and exhaustion can blunt these signs. Therefore:

• Do not diagnose pain from tachycardia alone.
• Do not conclude “no pain” because vital signs are normal.
• Use physiological changes to prompt questions and reassessment, not to overrule a reliable self-report.
• In infants and non-verbal patients, combine behaviour, physiological signs, context and caregiver observation.

8. Adult assessment in common emergency contexts

Presentation	Critical pain assessment	Do not miss
Chest pain	Onset, exertion, pressure/tearing quality, radiation, dyspnoea, sweating, nausea, syncope, risk factors and vital signs.	Acute coronary syndrome, aortic syndrome, pulmonary embolism, pneumothorax, pericarditis, oesophageal rupture.
Abdominal pain	Migration, meals, vomiting, stool/flatus, urine, pregnancy possibility, bleeding, surgery, distension and guarding.	Perforation, obstruction, ectopic pregnancy, pancreatitis, sepsis, ischaemia, ruptured aneurysm.
Headache	Thunderclap onset, first/worst headache, fever, neck stiffness, trauma, pregnancy/postpartum, focal deficit, seizure and visual change.	Subarachnoid haemorrhage, meningitis, stroke, cerebral venous thrombosis, raised intracranial pressure.
Back pain	Trauma, cancer, fever, intravenous drug use, immunosuppression, neurological deficit, saddle symptoms and bladder/bowel function.	Spinal cord compression, cauda equina, epidural abscess, fracture, aneurysm, renal disease.
Limb pain	Onset, swelling, colour, temperature, pulses, sensation, movement, trauma, immobilization and anticoagulation.	Compartment syndrome, acute limb ischaemia, deep-vein thrombosis, necrotizing infection, fracture.
Sickle-cell or recurrent crisis	Usual crisis pattern, chest symptoms, fever, neurological change, hydration, previous complications, medicines and response.	Acute chest syndrome, sepsis, stroke, splenic sequestration, aplastic crisis or another diagnosis.

9. Assessing children and adolescents

9.1 Developmental approach

• Newborns and infants: observe cry, facial expression, consolability, limb tone, breathing, sleep and feeding. Ask the caregiver what is different from baseline.
• Toddlers and preschool children: use simple concrete words, play or drawing; ask them to point to the place that hurts. Do not promise “no injection” unless certain.
• School-age children: use body maps, faces, numbers when understood, and ask about function and worries.
• Adolescents: speak privately for part of the assessment, protect confidentiality within safety limits and ask about mood, self-harm, substances, sexual health and family stress when appropriate.

9.2 Child-specific questions

• What was the child doing when it started? Is there fever, trauma, vomiting, rash, breathing difficulty or reduced urine?
• Can the child walk, play, eat, drink, sleep or attend school as usual?
• What does the child think is happening? What does the caregiver fear?
• What analgesics, traditional medicines or household products have been given, in what amount and at what time?

9.3 Behaviour and observation

Look for consolability, interaction, guarding, facial changes, cry, posture, withdrawal, altered play, sleep and feeding. A child may become quiet and immobile rather than cry. Observe before touching, during examination and after comfort measures. Use the same validated tool at each review.

10. Non-verbal adults and altered consciousness

• Attempt self-report using the person’s preferred communication method before relying on observation.
• Ask family or carers about baseline facial expression, movement, sleep, appetite and behaviour.
• Search for common causes: fracture, pressure injury, urinary retention, constipation, infection, dental disease, procedures, spasticity and medication withdrawal.
• Use an observational tool consistently and document the observed behaviours, not merely “appears comfortable.”
• Reassess after a proportionate comfort intervention; response supports but does not prove that pain was the only cause.

11. Investigations: targeted, not automatic

Investigations should answer a clinical question generated by history and examination. Depending on context, they may include glucose, full blood count, renal/liver tests, urinalysis, pregnancy testing, ECG, troponin, cultures, imaging or neurological studies. In palliative care, ask whether a test will change management or goals; avoid burdensome tests that add no benefit, while never using palliative status as a reason to ignore a reversible emergency.

12. Reassessment and response to intervention

When to reassess	What to record
After an initial intervention or transfer	Pain score, site/quality, vital signs, mental state, function, adverse effects and whether the suspected emergency is improving.
After a procedure or movement	Rest pain, movement/incident pain, wound or procedure findings and patient goal.
At each medication review	Benefit, sedation, respiratory status, nausea, constipation, confusion, allergy, adherence and interactions.
At handover	Current pain, trend, mechanism suspected, red flags, investigations pending, plan and escalation threshold.
At discharge or home review	Patient/caregiver teach-back, written plan, warning signs, access to medicines, transport and named contact.

13. Documentation template

14. Common assessment errors

• Asking only for a number and failing to locate or characterize the pain.
• Assuming pain is explained by a known cancer, diagnosis or previous visit without checking for a new cause.
• Using an adult scale in a young child or an observational scale when the patient can self-report.
• Interpreting a child’s selected face as their facial appearance rather than the intensity they feel.
• Allowing family members to answer every question without giving the patient a voice.
• Ignoring function, sleep, mood, caregiver strain, cost and cultural meaning.
• Withholding analgesia until every investigation is complete, or giving treatment without reassessment.
• Failing to document the scale, time, context, intervention and response.

15. Clinical cases

16. Quick self-test

1. What does SOCRATES stand for?
2. Why should physiological signs not replace self-report?
3. Name three self-report scales and three observational or developmental tools.
4. What must be assessed in a child who cannot describe pain?
5. Give five pain-related emergency red flags.
6. What should a complete pain note contain?

Answers

1. Site, Onset, Character, Radiation/region, Associations/aggravating and relieving factors, Timing/time course, Exacerbating/effect, and Severity.
2. They are influenced by age, shock, medication, chronic illness, autonomic disease and stress; normal signs do not exclude pain and abnormal signs are not specific.
3. Examples of self-report: NRS, VAS, verbal descriptor and Wong–Baker FACES. Examples of observational/developmental tools: FLACC, NIPS, CRIES, PAINAD and CPOT.
4. Behaviour, physiological changes, caregiver report, context, examination, possible causes, function and response to a carefully monitored comfort measure.
5. Examples: chest pain with shock, acute abdomen, neurological deficit with back pain, limb neurovascular compromise, thunderclap headache, fever with confusion, major trauma or suicidal/violent risk.
6. Source, site, onset, character, radiation, associations, timing, severity/tool, function, goal, examination, vital signs, suspected cause/mechanism, action, response, adverse effects, escalation and follow-up.

Key take-home points

• Begin with safety and ABCDE; detailed assessment follows stabilization.
• The patient’s report is primary when reliable; inability to communicate does not equal absence of pain.
• SOCRATES organizes history, while body maps, function, examination and context make it clinically useful.
• Use validated tools matched to age, development and communication ability, and record trends rather than isolated scores.
• Assess total pain and the practical realities of care at home.
• Reassess after every intervention and escalate new, severe, changing or neurologically associated pain.

Further study and references

• Clinical Assessment of Pain in Adults and Children — Makerere University reference
• IASP terminology and pain definitions
• IASP curriculum outline on pain for medicine
• WHO: Palliative care
• NICE: Chronic pain assessment and management
• Related lesson: Description, classification and physiology of pain

Educational resource for supervised learning. Apply current Uganda clinical protocols, local formularies and senior advice.