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 |
Sources:
- Adapted from Clinical Nursing Pocket Guide
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This is a great article. Thanks! I really find this useful.