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The A-Z of Nursing Assessment Tools

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by Matt Bodell.
The A-Z of Nursing Assessment Tools

Nursing Assessment Tools help you to provide safe and evidence based care to patients.

A nurses toolbox is overflowing with various patient assessments - each of which is designed to help you in providing safe and evidenced based care. Below is a list of the most popular nursing assessments tools used in practice - everything from pain management to ensuring adequate staffing.

Abbreviated mental test (or AMT or mini-mental or MMSE) is used to rapidly to assess elderly patients for the possibility of dementia, delirium, confusion and other cognitive impairment.


ABCDE is a comprehensive and systematic assessment of a patients physiology; airway, breathing, circulation, disability and exposure.

AVPU (alert, voice, pain, unresponsive) is an assessment used to measure a patients level of consciousness. See GCS.

Addenbrooke’s Cognitive Examination (or ACE) –  Well validated assessment tool for clinic setting assessment of cognitive functioning. This measures cognitive domains including language, visuospatial, memory and attention.  Usage is usually in part with other screening tests such as blood test, ECG and MRI scan to inform a diagnosis.

Alcohol Use Disorders Identification Test (or AUDIT) – A basic screening tool used to pick up the early signs of hazardous and harmful drinking and identify mild dependence and highlight if a need for assisted withdrawal is required.

Body mass index (BMI) is a measure of body fat based on your weight in relation to your height, and applies to most adult men and women aged 20 and over.

Braden Score (or Braden Scale) is used to predict pressure ulcer risk. It provides an estimated risk for the development of a pressure sore in a patient. See Waterlow score. 

BUFALO assessments are used to ensure compliance with sepsis bundles; Blood cultures, Urine output measurement, IV Fluids, antibiotics, Lactate measurement and Oxygen.

Beck Depression Inventory (or BDI) is a 21-item rating system that measures characteristic attitudes and symptoms of depression.

Bed Rails Assessment is used to help risk assess the use of bed rails with a patient.

Catheter Assessment is a check to ensure the device is still required, that the device is clean, shows no signs of wear, a fixation device is used and the catheter bag is in-date.

Cubbin & Jackson is used to predict pressure ulcer risk in a critical unwell patient, usually on intensive care. It provides an estimated risk for the development of a pressure sore in a patient.

Confusion Assessment Method (or CAM) is intended to assist with identifying the symptoms of confusion or delirium.

CAM-ICU is an adaptation of the confusion assessment method tool for use in ICU patients. See RASS.

Centor score are a set of criteria which may be used to identify the likelihood of a bacterial infection in adult patients complaining of a sore throat.

CRE Assessment (Carbapenem Resistant Enterobacteriaceae) is a screening tool used to look for the signs of CRE.

DisDAT is intended to help identify distress cues in people who because of cognitive impairment or physical illness have severely limited communication.

Early warning score (or EWS, MEWS, NEWS, PEWS) is a guide used to quickly determine the degree of wellness of a patient. It is based on the six cardinal vital signs; Respiratory rate, SaO2, Temperature, Blood pressure, Heart rate and AVPU / GCS response. Some scores also include urine output.

FAST (face, arm, speech test) is used to assess stroke-like symptoms in a patient.

Falls risk assessment tool (or FRAT) is used to predict a patients risk of falling either in hospital or at home.

FRAX tool was developed to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated.

FLACC (face, legs, activity, cry, consolability) is a behavioural pain assessment tool designed for use on paediatric or non-verbal patients.

Glasgow Coma Scale (or GCS)  is a neurological scale aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

Glasgow Depression Scale is designed to assess mood and the risks of depression on patients with learning disabilities.

Global Registry of Acute Coronary Events (or GRACE score) score is used for risk assessment in ACS (acute coronary syndrome) which includes n-stemi, stemi and unstable angina.

Generalised Anxiety Disorder Questionnaire (or GAD-7) – Screening tool used to measure the severity of Generalised Anxiety Disorder. 7 questions that can be administrated by a health care professional or self-administrated by the client themselves.

Hourly rounding is used to ensure patients are seen and assessed at least once an hour. It is useful in patients who are unlikely to call for help if needed i.e. dementia, delirium or children.

Hospital Anxiety and Depression Scale (or HADS) – Used for Anxiety & Depression can be used in community as well as hospital. It is a 14 question Psychological screening tool assessing the severity of symptoms.

Hs and Ts -A variety of disease processes can lead to a cardiac arrest; however, they usually boil down to one or more of the “Hs and Ts”.

Liverpool University Neuroleptic Side Effect Rating Scale (or LUNSERS) – Is a self-assessment tool for measuring the side-effects of antipsychotic medications. Red herrings are included to check the accuracy of the results. The 51 questions are based on true side effects with 10 being false  ones aim to help patients Identify, understand and gain awareness of side effects they could be experiencing.

Manchester Triage System (or MTS) is the most widely used A&E triage system in the UK, Europe and Australia, it assigns patients a priority and time-scale in which to be seen in emergency departments.

MUST is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese.

Mini PAS-ADD is an assessment tool for undertaking mental health assessments with people with learning disabilities

Moving & Handling Assessments are designed to ensure patients and staff are safe when providing patient care. The assessment shows the amount of staff, if any, required to assist the patient with mobilisation, pressure area care etc.

MRSA Assessment (Methicillin-resistant Staphylococcus Aureus) is a risk assessment used to determine a patients MRSA risk status and if appropriate decolonisation needs to be undertaken.

Neonatal Pain, Agitation & Sedation Score (or N-PASS) is used, usually in neonatal intensive care, to assess an infants pain, agitation and sedation levels using body language and verbal responses.

PQRST (provocation/palliation, quantity/quality, region/radiation, timing) is a valuable tool to accurately describe, assess and document a patient’s pain. The method also aids in the selection of appropriate pain medication and evaluating the response to treatment.

Two-stage capacity test is used to decide whether an individual has the capacity to make a particular decision, it comprises of two questions: Stage 1. Is there an impairment of or disturbance in the functioning of a person’s mind or brain? If so, Stage 2. Is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision?

Traffic Light Assessment is designed for children or patients with a learning difficulty to help communicate likes, dislikes and preferences to staff the patient may not know.

Venous thromboembolism assessment  (or VTE) is an assessment used to determine a patients risk of having a deep vein thrombosis (or DVT). It usually assess the patients mobility

Safer Nursing Care Tool (or Safer Staffing, Acuity, Dependency) is designed to assess the dependency of patients and any interventions required to ensure adequate and safe staffing levels.

SBAR (Situation, Background, Assessment, Recommendations) is the nationally recognised communication and assessment tool used in the UK. It provides an structured way to assess and communicate care. See ABCDE.

SBEAR (Situation, Background, Examination, Assessment, Recommendations) is a variation of the SBAR framework. See SBAR. 

SPICT (Supportive & Palliative Care Indicators Tool) is used to identify people at risk of deteriorating and dying with one or more advanced conditions. Primarily used for palliative care needs assessment and care planning.

SOCRATES is a mnemonic acronym used by health professionals to evaluate the nature of pain that a patient is experiencing; Site – Where is the pain? Or the maximal site of the pain. Onset – When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive. Character – What is the pain like? An ache? Stabbing? Radiation – Does the pain radiate anywhere? (See also Radiation.) Associations – Any other signs or symptoms associated with the pain? Time course – Does the pain follow any pattern? Exacerbating/Relieving factors – Does anything change the pain? Severity – How bad is the pain?

Richmond Agitation-Sedation Scale (or RASS)  is one of many sedation scales used in medicine to determine a patients agitation or sedation level. Other scales include the Ramsay scale, the Sedation-Agitation-Scale, and the COMFORT scale for paediatric patients. See CAM-ICU.

Waterlow score (or Waterlow scale) is used to predict pressure ulcer risk. It provides an estimated risk for the development of a pressure sore in a patient. See Braden score. 

WHO Checklist was designed to reinforce accepted safety practices and foster better communication and teamwork between clinical disciplines it includes team introductions, checking the patients identity and confirming the proposed operation including consent forms.

Wong-Baker FACES Pain Rating Scale is a pain assessment tool designed around a set of faces which display different emotions.

Wells criteria is used for diagnosing deep vein thrombosis risk or diagnosing pulmonary embolism risk. See VTE assessment.

Visual infusion phlebitis score (or VIPS) is an essential tool that facilitates the timely removal of short peripheral intravenous catheters at the earliest signs of infection.

Do you have one to add to the list? Let us know.

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NMC launches new educational standards to 'shape the future of nursing'

Part of the changes includes the removal of the cap on the number of hours students can spend on simulation activities.

Published on

by Ian Snug.
NMC launches new educational standards to 'shape the future of nursing'

Student nurses will start to train against the new standards from January 2019.

Last week the Nursing and Midwifery Council (NMC) launched 'ambitious' new standards of proficiency that set out the skills and knowledge the next generation of nurses need.

Alongside the new proficiencies, the NMC has introduced a more modern and innovative approach to the way universities and their practise partners train nurses and midwives - the NMC claim these changes will allow greater independence of assessment, and greater innovation by placement providers.


The NMC has also removed its standards for medicines management and instead encourages employers to instigate rigorous medicines management procedures.

Unlimited simulation.

Finally, part of the changes includes the removal of the cap on the number of hours students can spend on simulation activities - despite concerns this could reduce the total amount of time student nurses could spend on placements.

The new standards represent two years’ work and have been developed alongside nurses - as well as students, educators, healthcare professionals, charities and patient groups from across the UK.

Jackie Smith, NMC Chief Executive and Registrar, said: “Our new standards represent a huge leap forward. They raise the bar for the next generation of nurses and not only match the demands of the role but the ambition of the profession. This is vital as in the coming years many thousands of new professionals will join our register, delivering care to millions of people.

“We’ve also overhauled the way universities train nurses and midwives. They’ll be given more flexibility to harness new ways of working and embrace technology so they can equip the nurses and midwives of tomorrow with the skills they need to deliver world class care for years to come.”

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Do I really need to count a patients respiratory rate for a whole minute?

Just four breaths either side of the normal range could be indicative of impending clinical deterioration.

Published on

by Matt Bodell.
Do I really need to count a patients respiratory rate for a whole minute?

Some staff feel that sixty seconds can be better spent.

It is well documented that the respiratory rate is the least accurately recorded vital sign but yet it can be the most important.

Reseach suggests that many students and registered nurses believe they are enhancing patients' outcomes by performing tasks other than counting a patient's respiratory rate for the full sixty seconds.


The research, completed by Flenady et al, suggests that this debate isn't rooted in laziness but instead staff believe they are enhancing patients' outcomes by performing tasks other than counting a patient's respiratory rate.

Do I really need to count for a whole minute?

Yes! It is vitally important you count a patients respiratory rate for the full sixty seconds rather than counting for a shorter period and multiplying, or worse, estimating.

Respiration has differing patterns and without observing these for a whole sixty seconds you are unlikely to obtain an accurate measurement.

Do I really need to count a patients respiratory rate for a whole minute?

The critically unwell patient also sometimes tend to have apneic episodes and counting for a short period may not reveal these until a patient is in full respiratory arrest.

Just four breaths either side of the normal range could be indicative of impending clinical deterioration.

Finally, documenting an inaccurate respiratory rate could, potentially, have legal implications.

How should I count a respiratory rate?

You should count each full cycle of inspiration and expiration for a full sixty seconds.

Anecdotally, it is better to count a patients respiratory rate when a patient when they are not aware you are doing so - this ensures a patient is less conscious about their breathing and thus their respiratory rate is more natural.

Why is respiratory rate important?

Haemostasis and the bodies compensatory mechanisms mean that a change in respiratory rate could be one of the first indicators of deterioration in physiological condition.

Changes to a patients respiratory rate can indicate a number of things such as hypoxia, neurological or metabolic changes.

Picking up on these changes early should lead to earlier medical intervention and therefore better patient outcomes.

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Student nurses to receive ‘political lobbying lessons’

The session is designed to equip students with practical skills and knowledge they can use to develop a good relationship with their local MP.

Published on

by James M.
Student nurses to receive ‘political lobbying lessons’

Nursing students will learn how they can work with MPs to promote the nursing profession in a new training session organised by the RCN.

Members of the RCN’s student committee and student information officers - the RCN’s representatives in universities - will learn their way around the UK parliament and the government from the UK Parliament Outreach and Engagement Service.

The session is designed to equip students with practical skills and knowledge they can use to develop a good relationship with their local MP.


The RCN’s public affairs team will talk through the college’s approach to engaging with parliamentarians, especially the crucial role members can play. The team will explain different tactics and approaches students can take as well as what they can ask MPs to do to show their support for nursing staff in their constituencies.

Janet Davies, chief executive and general secretary of the RCN, said: “To work effectively, any union must be able to engage MPs and ministers.

“We know our members make the most powerful advocates for the profession. When frontline nursing staff sit in front of parliamentarians, you can see they listen.

“It’s through the hard work of members that vital issues such as safe staffing, harassment and health policy reach the top of the agenda.

“When nursing faces challenges on every front, the RCN wants to make sure our advocates are fully-equipped.”

Charlotte Hall, chair of the students’ committee, said: “Student nurses represent the future of the profession. Learning to engage with MPs is vital if we are to effectively shape that future and ensure the best possible care for patients.

“With these skills, committee members and student reps will be able to help other nurses make their voices heard on behalf of the profession and patients.”

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