Which method is the most accurate way to determine the pain level of a patient who is alert and oriented?

Have you heard, "The patient is unconscious, breathing, and talking" and thought, "Huh?"

AVPU (pronounced as ave poo) or the AVPU scale — a tool used to assess the patient's brain perfusion and function — describes a patient's level of consciousness. All healthcare providers, including EMTs, doctors, nurses and paramedics, use AVPU to assess and monitor a patient's brain function.  

What does AVPU mean? 

A = Awake. The patient is Awake

V = Verbal. The patient responds to a Verbal stimulus

P = Pain. The patient responds to a Pain stimulus 

U = Unresponsive. The patient is Unresponsive to stimulus 

The distinction between 'A' and 'V' frequently causes confusion.

You are awake on AVPU scale

If you are reading this article, you are 'A' on AVPU. You might be awake and confused, awake and disoriented, awake and lethargic, or awake and oriented. Those descriptors for awake, such as confused or disoriented, describe your mental status. 

Awake patients are always conscious and some adjective that describes their mental status of being awake.

Being Not Awake is unconscious

A patient that is not awake is unconscious. A patient who is unconscious is V, P, or U on the AVPU scale.

A patient that is 'V' responds to a verbal stimulus provided by responders.

Have you ever yelled, "DUDE, wake up!" to an intoxicated patient (or friend) and they raised their eyes, looked at you, or somehow responded to your voice? They are responding to a verbal stimulus.

If the patient responds, "Why are you yelling at me?" the patient is 'A' or Awake.

A patient that is 'V' cannot be alert, answer SAMPLE history questions, describe their chief complaint or make an informed decision about refusing care.

Interpreting a pain stimulus 

If the patient doesn't respond to a verbal stimulus attempt a pain stimulus with a pinch, squeeze or sternum rub. 

A sternum rub is the application of a painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli. The sternum rub is the most common painful stimulus practiced in the field by EMTs and paramedics. However, it is possible to misinterpret the patient’s response to the stimuli depending on the duration the pressure is applied. 

Learn how to correctly apply and interpret a sternum rub. 

Glasgow Coma Scale

An alternative to the AVPU scale to assess a patient's level of consciousness is the Glasgow Coma Scale. 

How to use AVPU

Knowing the patient's level of consciousness - A, V, P, or U - is the beginning of an investigation. If the patient is awake and has altered mental status use the focused history (SAMPLE, OPQRST) and physical exam to determine why. Does the patient have low blood sugar, other symptoms of a stroke, or signs of a narcotics overdose? 

For a patient who is V, P, or U, there is increased urgency to determine the cause and provide treatment. For example, a patient who is unconscious may not be able to control their own airway. Seek out a cause and provide treatment within your scope of practice. 

Finally, reassess AVPU during treatment and transport. Monitoring AVPU and other vital signs will help determine if the patient is improving, worsening or responding to treatment.  

This article, originally published 8/18/2009, has been updated with additional information.
 

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Page 2

1. The table shows the Behavioral Pain Scale (BPS) (first column), the Critical Care Pain Observation Tool (CPOT) scores (second column), and the BPS and CPOT combination score (third column). The individual BPS and CPOT scores for each raw were summed. The BPS and CPOT combination score was obtained from the individual BPS and CPOT combination score from each raw. This combined BPS and CPOT score ranges from 3 to 20