How to: Perform Nursing Assessment Effectively

Nursing Procedures |

They say that “the best nurses are excellent at assessment”, this is true because if we would look at the nursing process, assessment is the first step. If you have a weak foundation in assessment, the rest follows. This is a post to help you perform Nursing Assessment.

So, here are a list of keywords, assessment mnemonics which you can use to quickly and accurately assess a variety of patients.

ASSESSMENT 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 response 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 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.
U	Unresponsive	Patient does not response to any stimuli.	No response at all.

SAMPLE HISTORY ASSESSMENT

Description
S	Symptoms	“What’s wrong?” “What brings you to the hospital?”	Patient’s chief complaints
A	Allergy	“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
M	Medications	“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.
P	Past 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.
L	Last 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.
E	Events 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

D	Deformities
C	Contusions
A	Abrasions (Consider bony prominences for pressure sores)
P	Punctures or Penetrations
B	Burns
T	Tenderness
L	Lacerations
S	Swelling

CAGE: Diagnostic Tool for Alcohol Problems

Description		Sample Question
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?

ABCDEFGHI TRAUMA ASSESSMENT

Description
A	Airway
B	Breathing
C	Circulation
D	Disability (neurologic status)
E	Expose (remove clothing, keep the patient warm)
F	Full set of vital signs
G	Give comfort measures
H	History/Head-to-Toe assessment
I	Inspect posterior surfaces

CAUTION: SEVEN WARNING SIGNS OF CANCER

Description
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