Before We Start
Why pain assessment is more complex than "rate your pain 1–10"
A pain scale number (0–10) tells you how intense the pain is. It tells you nothing about where it is, what kind of pain it is, what makes it worse, what makes it better, or how it has changed since the last assessment. A 6/10 sharp stabbing pain in the chest is very different from a 6/10 dull aching pain in the lower back — but the number alone doesn't distinguish them.
OLDCART gives you the complete picture. It's the difference between charting "patient reports pain 6/10" and charting information that actually guides clinical decisions.
💡 Pain Is Always Subjective
Pain is whatever the patient says it is, whenever they say it occurs.
This is the foundational nursing principle of pain assessment. You cannot objectively measure a patient's pain. You cannot tell a patient their pain is "not that bad" based on how they look. Believe the patient's self-report.
Cultural, psychological, and physiological factors all affect pain expression. Some people cry at a pain of 3. Some people rate a pain of 9 calmly. Neither is wrong.
The Seven Components
OLDCART — what to ask for each
O — Onset
When did the pain start? What were you doing?
Onset establishes the timeline and often reveals the cause.
Key questions:
• "When did you first notice the pain?"
• "Did it come on suddenly or gradually?"
• "What were you doing when it started?"
Why it matters: Sudden onset chest pain during exertion suggests cardiac ischemia. Gradual onset abdominal pain over days suggests a different process than sudden severe abdominal pain. Sudden severe headache ("worst headache of my life") is a red flag for subarachnoid hemorrhage.
💊 "Worst headache of my life" + sudden onset = subarachnoid hemorrhage until proven otherwise. Do not give pain medication and send home. This is an emergency.
L — Location
Where is the pain? Does it radiate?
Location pinpoints the anatomical source — or reveals referred pain patterns.
Key questions:
• "Can you point to where it hurts?"
• "Does the pain stay in one place or does it move or spread anywhere?"
• "Is it on the surface or deep inside?"
Referred pain patterns to know:
• Cardiac pain → left arm, jaw, back, epigastrium
• Appendicitis → starts periumbilical, moves to RLQ (McBurney's point)
• Gallbladder → right shoulder (referred via phrenic nerve)
• Kidney stones → flank to groin (colicky, follows ureter)
• Aortic aneurysm → tearing pain radiating to the back
💊 Chest pain radiating to the left arm and jaw in a diaphoretic patient = cardiac until proven otherwise. Obtain 12-lead EKG within 10 minutes. This is the NCLEX standard.
D — Duration
How long has it been there? Is it constant or intermittent?
Duration reveals the pattern and helps differentiate acute from chronic pain.
Key questions:
• "How long have you had this pain?"
• "Is it there all the time or does it come and go?"
• "If it comes and goes, how long does each episode last?"
Clinical significance:
• Constant pain — suggests ongoing tissue damage or inflammation
• Intermittent/colicky pain — suggests obstruction (gallstone, kidney stone, bowel obstruction)
• Pain that has been present for years vs. new pain — very different urgency levels
• Worsening chronic pain — may indicate disease progression
💊 Colicky (comes in waves, severe when present) abdominal pain + nausea/vomiting + no bowel sounds = bowel obstruction until proven otherwise.
C — Character
What does the pain feel like? What words describe it?
The quality of pain often points directly to its source.
Pain quality descriptors and what they suggest:
• Sharp, stabbing — pleuritic chest pain, peritonitis, nerve pain
• Dull, aching — musculoskeletal, visceral organs (kidney, liver)
• Burning — nerve pain (neuropathy), esophageal reflux, skin
• Crushing, pressure, squeezing — classic cardiac ischemia ("elephant sitting on my chest")
• Tearing, ripping — aortic dissection (emergency)
• Cramping — muscle, uterine, bowel
• Throbbing — vascular (migraine, dental abscess)
Let the patient use their own words first. Then offer descriptors if they struggle.
💊 "Tearing pain in the chest that radiates to my back" = aortic dissection until proven otherwise. BP difference between arms >20 mmHg confirms suspicion. Surgical emergency.
A — Aggravating Factors
What makes the pain worse?
Aggravating factors help identify the source and guide interventions — you can't relieve pain effectively if you don't know what's making it worse.
Key questions:
• "Is there anything that makes the pain worse?"
• "Does movement, breathing, eating, or position affect it?"
Examples:
• Pain worse with deep breathing → pleurisy, rib fracture, PE
• Pain worse with eating → peptic ulcer, gallbladder, pancreatitis
• Pain worse with movement → musculoskeletal, fracture
• Pain worse when lying flat → GERD, heart failure, pericarditis
• Pain on passive stretch of muscles → compartment syndrome (urgent)
💊 Chest pain that gets WORSE when lying flat and BETTER when leaning forward = pericarditis. This is a classic NCLEX pattern.
R — Relieving Factors
What makes the pain better?
Relieving factors guide your interventions and help validate the suspected diagnosis.
Key questions:
• "Is there anything that makes the pain better?"
• "Does rest, position, medication, heat, or cold help?"
Examples:
• Pain relieved by nitroglycerin → cardiac ischemia (angina responds; MI may not)
• Pain relieved by eating → peptic ulcer (duodenal ulcer in particular)
• Pain relieved by leaning forward → pancreatitis, pericarditis
• Pain relieved by rest → musculoskeletal, angina
• Pain NOT relieved by anything → peritonitis, MI, severe infection
💊 Nitroglycerin relieves angina but may or may not relieve MI pain. Relief with nitro is a supporting clue for cardiac origin — but lack of relief does not rule out MI.
T — Treatment
What has the patient already tried? What worked?
Knowing what treatment has already been attempted — and whether it helped — prevents duplication and guides next steps.
Key questions:
• "Have you taken anything for the pain? Did it help?"
• "Have you seen a doctor for this before?"
• "What treatments have you tried — medications, heat, ice, rest?"
Why it matters:
• A patient who says "I took four ibuprofen and it didn't help at all" gives important information — NSAIDs didn't touch it, which may point toward a more serious cause
• Document what the patient has already taken — prevents accidental double dosing
• Tells you where to start with new interventions
💊 Always ask what medications the patient took at home before arrival. A patient who took 1000mg of acetaminophen 2 hours ago cannot receive another dose for 4 more hours without risk of hepatotoxicity.
Pain Scales
Choosing the right scale for the right patient
NRS — Numeric Rating Scale (adults)
0 = no pain, 10 = worst pain imaginable. Most commonly used. Requires the patient to be alert and able to understand numbers. Ask: "On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, how would you rate your pain right now?"
FACES Scale (children 3+, cognitively impaired adults)
Six cartoon faces ranging from smiling (0, no pain) to crying (10, worst pain). Patient points to the face that matches how they feel. Does not require numerical understanding.
FLACC Scale (infants, non-verbal patients)
Face, Legs, Activity, Cry, Consolability. Each scored 0–2. Total score 0–10. Used for patients who cannot self-report. Observational — nurse scores based on behavior.
CPOT — Critical Care Pain Observation Tool (ICU, intubated)
Facial expression, body movements, muscle tension, ventilator compliance or vocalization. Used for sedated or intubated patients who cannot self-report.
🏥 Clinical Scenario — Full OLDCART Assessment
Ms. Reyes, 52 years old, presents to the ED reporting chest pain. You perform a complete OLDCART assessment.
O
Onset: "Started about 2 hours ago while I was walking up the stairs. Came on suddenly." → Exertional onset, sudden = cardiac flag.
L
Location: "Right here in the middle of my chest." Points to sternum. "And it goes up into my jaw and down my left arm." → Classic radiation pattern for cardiac ischemia.
D
Duration: "It's been there constantly for 2 hours. It hasn't let up." → Constant for 2 hours = more concerning than brief angina (which typically resolves in <15 min with rest).
C
Character: "It feels like pressure — like something heavy is sitting on my chest. And a squeezing feeling." → Pressure + squeezing = classic MI descriptors.
A
Aggravating: "It gets worse when I walk or move. Just resting helps a little." → Exertional worsening = cardiac.
R
Relieving: "Rest makes it a little better but it hasn't gone away. I took two aspirin at home." → Incomplete relief despite aspirin and rest = more consistent with MI than stable angina.
T
Treatment: "I took 325mg aspirin at home about an hour ago. Didn't really help. I've never had anything like this before." → Prior aspirin documented. No previous cardiac history — new presentation. 12-lead EKG obtained within 5 minutes of arrival. Troponin ordered. Nitroglycerin per protocol.
⚠️ The Trap — Equating Pain Behavior with Pain Severity
One of the most common and most harmful nursing errors: assuming a patient who "doesn't look like they're in pain" isn't really in pain.
Some people grimace and cry at a pain of 4. Some people calmly rate their pain as 9. Age, culture, prior pain experience, coping style, and individual physiology all affect pain expression. A patient who is laughing with family may still report 7/10 pain when asked directly.
NCLEX will test this: if a patient reports pain of 8/10 but "appears comfortable and is watching television" — the correct nursing action is to believe the patient's self-report and intervene for pain, not to conclude the patient is exaggerating.
Pain is whatever the patient says it is. Period.