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The A-Z of Clinical Assessment Tools for Nurses

BMI, MUST, Waterlow, AVPU, AMT – the list is endless.

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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.

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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 a 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.

Resources

Former student nurses share their top money-saving tips

“A nursing degree is very different to most undergraduate courses.”

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Student money saving tips

Direct from former student nurses, the Student Money Guide is packed with useful tips.

New nursing students should claim fuel reimbursements, car share, compare markets and supermarkets and seek second-hand textbooks to make their student funding, and part-time wages go as far as possible, updated advice from the Royal College of Nursing (RCN) says.

The College’s latest Student Money Guide for nursing is packed with useful information on childcare, travel expenses, charitable funding and tips for those moving into private rented accommodation.

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The top money-saving tips.

Direct from former student nurses, the guide offers some top money-saving tips, which include;

  1. Develop a good relationship with your bank – meet and go through all the options and accounts which will save you most money and give you the best interest rates
  2. Use online materials, the RCN Library for example, instead of buying textbooks – If you do buy them, try advertising on university notice boards for second-hand copies, or, have a look at www.abebooks.co.uk. Use cashback websites, such as Quidco, when making purchases.
  3. Get a Young Persons Rail Card if you spend over £72 a year on rail travel – all full-time students are eligible, regardless of age.
  4. Claim fuel reimbursement if you drive further to placement than to university – it is offered, so you might as well.
  5. Be penny-wise, seek out free pickings – go to sites like Freecycle for free furniture, kitchenware and bicycles.
  6. Check out your local discount warehouses for basics, cleaning products, toilet rolls, washing powder and buy these as a household to split the cost of a bulk buy – it is well worth it.
  7. Share lifts to placement and do food shops with fellow students.
  8. Make sure your supermarket shop is cheapest – check online comparison sites like mysupermarket.com ahead of your shop.
  9. Use your local butchers and market.
  10. Take a packed lunch and flask to university – you will save a small fortune and probably eat better.

Nursing is different to other degree courses.

Claire Cannings, Senior Welfare Adviser commented: “A nursing degree is very different to most undergraduate courses. The placement element means there is less time for part-time work, and the long shifts mean childcare and travel is often more expensive.

“Fluency with finances, brilliance with budgeting and keeping clued-up on things complimentary can pay dividends. This can, in turn, impact positively on study and well-being through a student’s learning years and beyond. It’s amazing how many grants and funds students are entirely unaware of which is why we’ve collated all the information they need in one place.

“While the RCN will still be making the case to Government to invest in nursing education, we hope the guide will continue to be a valuable resource to our current and potential members.”

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Clinical Updates

Induction framework for General Practice Nurses launched

It also provides guidance for practices employing General Practice Nurses.

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The document provides a framework for both new and experienced general practice nurses.

NHS England, in collaboration with The QNI, has launched a new Induction Template for General Practice Nursing.

The Induction Template is has been designed to enable employers to ensure that nurses in a first career destination role in General Practice are well supported when taking their first career step in primary care.

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Not just useful for newly qualified nurses, the 51-page document provides an induction framework for all new general practice nurses, enabling them to develop key skills required for the role.

It also provides guidance for practices employing General Practice Nurses.

Nursing associates, health care assistants and student nurses preparing for a primary care placement may also find the template useful.

A great start to a long and exciting career’.

The author of the document, Queen’s Nurse and experienced nursing mentor and educator, Sharon Aldridge-Bent said; “Developing this template highlighted the urgent need for a comprehensive induction and orientation programme for all nurses new to general practice.

“This most certainly will assist with recruitment and retention of nurses in the primary care setting.”

Paul Vaughan, Head of Nursing Now England, responsible for the delivery of the GPN Ten Point Plan, said: “this new resource will enable employers to ensure they provide nurses new to general practice with a really good experience of working in the sector and ensure they have a great start to their long and exciting career working general practice.”

The resource underpinned by General Practice – developing confidence, capability and capacity – A ten-point action plan for General Practice Nursing (2017) contributes towards the overall strategic goals outlined in the General Practice Five Year Forward View.

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