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  • 1.  Pain assessment in Telephone Triage

    Posted 04-08-2025 09:57

    Does anyone know of any resources for guiding nurses in pain assessment in telephone triage? I did a quick lit search, and I see a lot of articles about pain assessment in telehealth- but seem to be referring to being on video- where the clinical provider can see the patient. But I couldn't find anything specific to pain assessment in telephone triage. 



    ------------------------------
    Karen Lafferty MSN,RN,CPN
    Clinical Supervisor- Office Hours Nurse Triage Program
    The Children's Hospital of Philadelphia
    267-250-4601
    laffertyk@chop.edu
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  • 2.  RE: Pain assessment in Telephone Triage

    Posted 04-09-2025 08:50

    Karen,

    Schmitt content has severity definitions in the background on each guideline.  For pain severity: 

    PAIN SEVERITY: 
    Assessment of Pain Severity: Base it on the child's current behavior. Ask: 'How bad is the pain?' and then, 'What does the pain keep your child from doing?' Do not ask: 'Is the pain Mild, Moderate or Severe?' Reason: Many parents and teens will choose 'Severe'.
    * MILD: doesn't interfere with eating or normal activities
    * MODERATE: interferes with eating some solids and normal activities
    * SEVERE: excruciating pain, interferes with most normal activities                                                                                                                                    
    ASSESSING PAIN SEVERITY IN NONVERBAL CHILDREN: CRYING AND OTHER CLUES
    * Always consider pain as a possible cause of fussiness or crying.
    * MILD: Up and active, not crying at time of call (or transient brief periods of crying), easy to console, will play, drinking fluids, doesn't awaken from sleep
    * MODERATE: Intermittent crying for longer times, takes longer to console, doesn't want to play,
    prefers to be held constantly, irritable or more fussy overall, fluid intake may be less than normal, awakening from sleep frequently, difficult to put back to sleep. In addition to crying, may have 'moaning or whimpering' due to pain.
    * SEVERE: Unable to do normal activities, unable to sleep or will only fall asleep briefly, may have poor fluid intake or refuse fluids, miserable, incapacitated, excessive or constant crying, difficult or impossible to console. NOTE: Instead of excessive or constant crying, may also be 'groaning, grunting, moaning or whimpering' due to severe pain                                                                                                            

    Hope this helps,



    ------------------------------
    Teresa Baird BSN RN CPN
    Nursing Quality Specialist
    Children's Hospital Colorado
    Elizabeth CO
    (720) 777-3537
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    Original Message


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