Self-reporting is considered the most reliable method of determining the severity of pain. Several tools have been created to assist with measuring a patient’ s pain through self-report. However, no single tool is appropriate for the assessment of all patients, and nurses should have knowledge and skills in using a range of pain tools that can be applied as required, depending on age and cultural factors such as language.
Suitable pain severity scales for use in a triage setting include a numerical rating scale( NRS), which is also known as a verbal pain score( VPS), and a visual analogue scale( VAS). These tools provide either a 100-point scale( NRS / VPS), or a 100-mm scale( VAS). For some patients, a verbal descriptor scale may be more suitable, using terms such as‘ no pain’,‘ mild pain’,‘ moderate pain’ and‘ severe pain’, or other appropriate descriptors as identified by the patient.
For young children, the Wong-Baker FACES Rating Scale is a commonly used tool. 62 This scale has also been adapted for use in other populations, for example in patients with limited ability to communicate in English; however, this practice has attracted criticism as it may be construed as being demeaning to the adult patient. Several culture-specific tools for both adult and paediatric patients have been developed with the recognition that care should be sensitive and responsive to cultural issues. Indeed, cultural variations need to be
63, 64 considered in the application of pain assessment tools.
The Abbey Pain Scale(‘ the Abbey’) is an Australian tool that has been designed to measure the severity of pain in people who have dementia and cannot verbalise their experience. 65 This tool provides a systematic approach to measuring the severity of pain at triage. A total score is calculated from responses to six items, each with a maximum score of three points( absent pain = 0; severe pain = 3). From a possible total of 18 points, a score of 0 – 2 is rated‘ no pain’, 3 – 7 is rated‘ mild’, 8 – 13 is rated‘ moderate’, and > 14 is rated‘ severe’. 66
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Pain severity scales can also be used to categorise self-reported pain into mild, moderate or severe pain. These categorisations can assist in determining an appropriate analgesia through the development of analgesic algorithms for paediatric and adult patients. 67
Application of a triage category
The descriptive terms listed in Table 7.1 should be used as a guide to acuity for the ATS. Table 7.1: Determining a triage category 2
Descriptor
ATS category
Very severe 2 Moderately severe 3
Moderate 4 Minimal 5
Department of Health and Ageing – Emergency Triage Education Kit