You walk into a patient’s room and they tell you, “My pain medicine isn’t working anymore.” Relying solely on a simple numeric rating (like “7/10”) is insufficient. To understand the full clinical picture and intervene effectively, you’ll need to ask clarifying questions.
A thorough pain assessment is one of the most critical responsibilities a nurse holds. It is foundational to ethical, quality, and safe patient care. When we accurately assess and document pain, we advocate for timely and effective interventions, leading to better outcomes.
This is where the PQRST mnemonic comes in. It is an evidence-based tool that moves beyond the simple numeric rating to gather the qualitative data required to identify the source of the pain and guide your treatment plan. Mastering PQRST turns a reactive response into a proactive, clinical assessment.
In this article:
- P – Provoking and Palliating Factors
- Q – Quality
- R – Region and Radiation
- S – Severity
- T – Timing
- Integrating PQRST into Practice & Documentation
- Conclusion: Mastering the Art of Pain Assessment
P – Provoking and Palliating Factors
The ‘P’ addresses the context of the pain: What makes it start, and what makes it stop (or feel better)?
The core question is: “What were you doing when the pain started? What makes it better or worse?”
Provoking Factors (Triggers/Worseners)
These are actions, movements, or environmental factors that trigger or worsen the pain.
- Examples: Does the pain increase when you walk, take a deep breath, or eat a fatty meal?
- Clinical Insight: Pain that worsens with movement often indicates a musculoskeletal injury, whereas pain that worsens with breathing can indicate pulmonary or cardiac involvement.
Palliating Factors (Relievers)
These are actions, positions, or medications that relieve or alleviate the pain.
- Examples: Does heat, ice, a change in position, or rest help? What pain medications have you tried, and did they work?
- Clinical Insight: Knowing what the patient has tried and its effectiveness is vital. It prevents redundant interventions and gives clues about the pain’s mechanism.
Q – Quality
The ‘Q’ helps you understand the subjective experience of the pain. If a patient just says their pain is “bad,” you haven’t learned anything useful.
The core question is: “Can you describe the pain in your own words?”
Your role as a nurse is to gently encourage the patient to use specific, descriptive adjectives. These descriptors are clinical gold, often pointing directly to the underlying pathophysiology.
Look for these common themes:
- Sharp, Stabbing: This quality often suggests nerve involvement, acute trauma, or visceral spasm (like kidney stones or gallbladder pain).
- Dull, Aching, Throbbing: These symptoms typically correlate with inflammation, muscle strain, or vascular/circulatory issues.
- Burning, Tingling, Numbness: These are hallmark signs of neuropathic pain, which is pain caused by damage or compression to the nerves (e.g., diabetic neuropathy).
- Crushing, Heavy, Squeezing: This description is CRITICAL and must be investigated immediately if the patient uses it to describe chest pain, as it is highly associated with possible cardiac ischemia (myocardial infarction/MI).
R – Region and Radiation
The ‘R’ defines the exact anatomical location and spread of the pain.
The core question is: “Where is the pain located right now? Does it move or spread anywhere else?”
Region
Ask the patient to physically point with one finger to the exact location(s). Don’t rely on generalized statements like “my stomach.” Asking them to point helps pinpoint tenderness and localize the affected area.
Radiation
Does the pain travel? Pain that starts in one area but radiates or spreads along a nerve pathway (like sciatica traveling down the leg, or arm pain related to a heart attack) is known as referred pain.
- Clinical Insight: Radiation to the jaw, shoulder, or arm can signal a cardiac emergency, regardless of the severity rating. Pain in the flank that radiates to the groin often suggests kidney stones.
S – Severity
The ‘S’ quantifies the subjective pain experience, enabling you to track trends and measure the effectiveness of interventions.
The core question is: “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, what would you rate your pain right now?”
Scales
- Numeric Rating Scale 0-10: Most common adult scale.
- Wong-Baker FACES Pain Rating Scale: Used for children or adults who may have cognitive or language barriers.
Context
Always ask for context to establish a baseline:
- What is the pain at its worst?
- What is the pain at its best?
- What is a tolerable pain level for them? (This defines your treatment goal.)
Nursing pearl: Achieving a pain level of “0” may not be realistic for all patients, especially those with chronic pain.
T – Timing
The ‘T’ determines the chronological flow of the pain (when it started and its pattern).
The core questions are: “When did the pain start? Is it constant or does it come and go?”
- Onset (When): Acute (sudden, hours/days) versus chronic (long-standing, lasting for months or years).
- Frequency (Pattern): Is the pain intermittent (comes and goes) or continuous (constant)?
- Duration: How long does a painful episode last if it is intermittent?
- Trend: Has the pain remained stable, worsened, or improved since it began?
Integrating PQRST into Practice & Documentation
A PQRST assessment is not performed in a vacuum. A holistic nurse assesses non-verbal cues as well: grimacing, guarding (protecting the painful area), restlessness, inability to focus, and changes in vital signs.
The ultimate value of PQRST lies in its application:
- Documentation: Every component of PQRST must be accurately and thoroughly documented in the patient’s medical record immediately following your assessment. A comprehensive documentation note based on the PQRST format may look like the following:
- P: Started suddenly after lifting a box this morning; slight relief with rest. Q: Continuous, dull, aching. R: Right side of lower back. S: 7/10. T: Onset 4 hours ago, continuous.
- Intervention & Reassessment: PQRST guides your next move—whether that’s administering an analgesic, applying heat, performing further tests or evaluation, or notifying a provider. Always remember the crucial final step: reassess the pain 30–60 minutes after intervention to ensure the treatment was effective and document the new PQRST findings.
Conclusion: Mastering the Art of Pain Assessment
PQRST is the essential framework for turning a subjective complaint into actionable clinical data. By consistently applying this systematic assessment, you move beyond merely treating a number to become the effective and compassionate clinician your patients rely on.
