They say the best nurses are excellent at obtaining assessment, and this is true! If nurses would look at the nursing process, assessment is the first and key step. Gathering information about the client will provide clues for what care you can give. If you have a weak foundation in assessment, the rest of the process follows.
But with the many ways to assess a patient, assessment has become an overwhelming process. To be more systematic, here are 6 nursing assessment mnemonics you can use to accurately and quickly assess variety of patients in different conditions.
AVPU is a mnemonic to assess for alertness.
|Description||Adult Behavior||Pediatric Behavior|
|A||Alert||Client’s eyes open spontaneously; appears aware of and responsive to the environment; follows commands eyes tract peoples and objects.||Child is active and responds appropriately to parents and other external stimuli.|
|V||Response to Verbal Stimuli||Patient’s eyes do not open spontaneously but open to verbal stimuli. Patient is able to respond in some meaningful way when spoken to.||Response only when his or her name is called by parents.|
|P||Response to Pain||Patient does not respond to questions but moves or cries out in response to a painful stimulus such as pinching the skin or earlobe.||Response only when painful stimulus is received, such as pinching the nail bed.|
|U||Unresponsive||Patient does not respond to any stimuli.||No response at all.|
2. SAMPLE for History Assessment
Remember SAMPLE when obtaining patient history.
||Patient’s chief complaints|
||Seeking to know what type of allergic reaction they experience|
||Prescribed, Over the counter, herbal meds and etc are asked.|
|P||Past Medical History||
||Seeking to know the previous state of health, and previous illnesses.|
|L||Last Oral Intake||
||Seeking what are the last oral intakes of the client.|
|E||Events leading up to the illness or injury||
||Seeking to know how his present status happened.|
3. DCAP-BTLS Rapid Assessment
DCAP-BTLS is especially useful during emergency cases.
|A||Abrasions (consider bony prominences for pressure sores)|
|P||Punctures or Penetrations|
CAGE mnemonic is a diagnostic tool for alcohol problems.
|C||Concern by the person that there is a problem||Have you ever felt that you should Cut down on your drinking?|
|A||Apparent to others that there is a problem||Have you ever become Annoyed by criticisms of your drinking?|
|G||Grave consequences||Have you ever felt Guilty about your drining?|
|E||Evidence of dependence or tolerance||Have you ever had a morning Eye opener to get rid of a hangover?|
5. ABCDEFGHI Trauma Assessment
The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for emergency cases.
|D||Disability (neurologic status)|
|E||Expose (remove clothing, keep the patient warm)|
|F||Full set of vital signs|
|G||Give comfort measures|
|I||Inspect posterior surfaces|
6. CAUTION for Seven Warning Signs of Cancer
The CAUTION mnemonic is used by the American Cancer Society to detect and recognize the early warning signs of cancer.
|C||Change in bowel or bladder habits|
|A||A sore throat that does not heal|
|U||Unusual bleeding or discharge|
|T||Thickening or lump in breast or elsewhere|
|I||Indigestion or dysphagia|
|O||Obvious change in wart or mole|
|N||Nagging cough or hoarseness|