6 Nursing Assessment Mnemonics

Nursing Mnemonics

Introduction

They say that “the best nurses are excellent at 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 mnemonics which you can use to accurately and quickly assess variety of patients in different conditions.

AVPU for Alertness

DescriptionAdult BehaviorPediatric Behavior
AAlertClient’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.
VResponse to Verbal StimuliPatient’s eyes do not open spontaneously but open to verbal stimuli. Patient is able to response in some meaningful way when spoken to.Response only when his or her name is called by parents.
PResponse to PainPatient does not response 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.
UUnresponsivePatient does not response to any stimuli.No response at all.

SAMPLE for History Assessment

Description
SSymptoms
  • “What’s wrong?”
  • “What brings you to the hospital?”
Patient’s chief complaints
AAllergy
  • “Are you allergic to anything?”
  • “What happens to you when you use something that you’re allergic to?”
Seeking to know what type of allergic reaction they experience
MMedications
  • “Are you taking any medications?”
  • “What are you taking the medications for?”
  • “When did you last take your medications?”
Prescribed, Over the counter, herbal meds and etc are asked.
PPast Medical History
  • “Have you had this problem before?”
  • “Do you have other medical problems?”
Seeking to know the previous state of health, and previous illnesses.
LLast Oral Intake
  • “When did you last eat or drink anything?”
  • “What was it that you last ate?”
Seeking what are the last oral intakes of the client.
EEvents leading up to the illness or injury
  • Injury: “How did you get hurt?”
  • Illness: “What led to this problem?”
Seeking to know how his present status happened.

DCAP-BTLS Rapid Assessment

DDeformities
CContusions
AAbrasions (Consider bony prominences for pressure sores)
PPunctures or Penetrations
BBurns
TTenderness
LLacerations
SSwelling

CAGE: Diagnostic Tool for Alcohol Problems

DescriptionSample Question
CConcern by the person that there is a problemHave you ever felt that you should Cut down on your drinking?
AApparent to others that there is a problemHave you ever become Annoyed by criticisms of your drinking?
GGrave consequencesHave you ever felt Guilty about your drining?
EEvidence of dependence or toleranceHave you ever had a morning Eye opener to get rid of a hangover?

ABCDEFGHI Trauma Assessment

The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for emergency cases.

Description
AAirway
BBreathing
CCirculation
DDisability (neurologic status)
EExpose (remove clothing, keep the patient warm)
FFull set of vital signs
GGive comfort measures
HHistory/Head-to-Toe assessment
IInspect posterior surfaces

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.

Description
CChange in bowel or bladder habits
AA sore throat that does not heal
UUnusual bleeding or discharge
TThickening or lump in breast or elsewhere
IIndigestion or dysphagia
OObvious change in wart or mole
NNagging cough or hoarseness

See Also

  1. Complete Head-to-Toe Physical Assessment Cheat Sheet
  2. Ultimate Guide to Head-to-Toe Physical Assessment
  3. Head-to-Toe Physical Assessment [VIDEOS]

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