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The A-Z of Nursing Assessment Tools

Matt B

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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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Lucozade is no longer as effective at treating hypoglycemia

James M

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Due to changes in its recipe and a significant reduction in glucose, Lucozade will not be as effective as a treatment for hypoglycemic patients.

Recipe changes to Lucozade Original Energy product line mean it will no longer be as effective at treating hypoglycemic patients – this is due to a 50% reduction in glucose based carbohydrates. Healthcare Professionals should seek guidance from their local specialist team on alternative treatment protocols.

This change applies to all Lucozade Energy Flavours. New products started appearing on shelves in April 2017. However, for a short time, both the new and old recipe will be available.

Previously, 100ml of Lucozade Original contained 17g of carbohydrate; this was reduced to 8.9g in April 2017.

According to Diabietes.co.uk, patients who experience a hypoglycemic episode are advised to consume 15-20g of sugar when treating low blood sugar, but this will no longer be equivalent to 100ml of Lucozade.

Lucozade Ribena Suntory, which also makes Ribena and Orangina, among other drinks, is lowering its sugar content by replacing these sugars with low-calorie sweeteners, such as aspartame.

You can also visit www.lrsuntory.com/health for more information on Lucozade’s changing nutritional values or speak to your local diabetes specialist team.

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Shift Planner for Nurses, Students & Support Staff

Matt B

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Shift planning is essential for safe care, some people using a piece of paper others have their thoughts well arranged in their head, either way everybody does it.

This shift planner has been designed with newly qualified nurses and student nurses in mind but would be suitable for anybody to use.

You can download our Shift Planner for FREE. You are free to download, print and distribute our shift planner as you wish. You will need a PDF reader on your PC to download. 

The planner has been created with two primary columns, one for your main nursing priorities and one to remind you to hand over jobs to the next shift. It also features a small key and area for general notes. Due to limited space we have only included enough room to plan up to eight patients, if you need more we encourage you print doublesided.

We encourage you to make comments or suggestions in the comments section below. The most popular will be implemented in a version 2.

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