Nurses rely on a diverse range of patient assessment tools to deliver safe and evidence-based care. These tools are crucial for evaluating patient conditions, guiding interventions, and ensuring optimal patient outcomes. This guide explores some of the most widely used nursing assessment tools in practice, covering areas from mental health and physical well-being to risk assessment and communication.
Abbreviated Mental Test (AMT) / Mini-Mental State Examination (MMSE)
The Abbreviated Mental Test (AMT), also known as the Mini-Mental State Examination (MMSE), is a brief and efficient tool used to screen elderly patients for potential cognitive impairments. It helps nurses quickly assess for dementia, delirium, confusion, and other cognitive issues. This rapid assessment is vital for early detection and appropriate care planning for elderly patients experiencing changes in mental status.
ABCDE Assessment
ABCDE is a systematic and comprehensive approach to patient assessment, focusing on the most critical physiological functions. It stands for Airway, Breathing, Circulation, Disability, and Exposure. This method ensures a structured evaluation of a patient’s vital signs and overall condition, allowing nurses to prioritize interventions based on immediate life-threatening issues. It’s a cornerstone of emergency and acute care nursing.
AVPU Scale
The AVPU scale (Alert, Voice, Pain, Unresponsive) is a rapid assessment tool used to determine a patient’s level of consciousness. It provides a quick and easy way to categorize a patient’s responsiveness, ranging from fully alert to unresponsive to stimuli. AVPU is often used in emergency situations and as an initial assessment, and it is sometimes used in conjunction with the Glasgow Coma Scale (GCS) for a more detailed neurological evaluation.
Addenbrooke’s Cognitive Examination (ACE)
The Addenbrooke’s Cognitive Examination (ACE) is a more detailed and validated assessment tool for evaluating cognitive function in clinical settings. It goes beyond basic screening to assess specific cognitive domains, including language, visuospatial abilities, memory, and attention. ACE is often used in conjunction with other diagnostic tests like blood work, ECG, and MRI scans to provide a comprehensive picture for diagnosing cognitive disorders.
Alcohol Use Disorders Identification Test (AUDIT)
The Alcohol Use Disorders Identification Test (AUDIT) is a screening tool designed to identify early signs of risky and harmful drinking habits. It helps nurses detect mild alcohol dependence and determine if a patient requires assisted withdrawal management. Early identification through AUDIT allows for timely intervention and support for patients struggling with alcohol misuse.
Body Mass Index (BMI)
Body Mass Index (BMI) is a widely used measure of body fat based on an individual’s weight and height. Applicable to most adult men and women aged 20 and over, BMI provides a standardized indicator of weight status and potential health risks associated with being underweight, overweight, or obese. It’s a simple yet valuable tool for initial health assessments and monitoring.
Braden Scale
The Braden Scale is a predictive tool used to assess a patient’s risk of developing pressure ulcers (bedsores). It evaluates various factors contributing to pressure ulcer risk, such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. By identifying patients at high risk, nurses can implement preventative measures and minimize the incidence of pressure injuries. See Waterlow Scale.
BUFALO Sepsis Assessment
BUFALO is a mnemonic for a set of assessments and interventions used to ensure compliance with sepsis bundles in managing patients with suspected sepsis. BUFALO stands for Blood cultures, Urine output measurement, IV Fluids, antibiotics, Lactate measurement, and Oxygen. These assessments and interventions are crucial in the timely and effective management of sepsis, a life-threatening condition.
Beck Depression Inventory (BDI)
The Beck Depression Inventory (BDI) is a 21-item self-report rating scale designed to measure the intensity of depressive symptoms and attitudes. It helps nurses and mental health professionals quantify the severity of depression and monitor treatment progress. BDI is a valuable tool for screening and tracking depression in various clinical settings.
Bed Rails Assessment
A Bed Rails Assessment is used to evaluate the risks and benefits of using bed rails for individual patients. This assessment helps ensure patient safety by considering factors like patient mobility, cognitive status, and fall risk when deciding whether bed rails are appropriate and safe for a particular patient.
Catheter Assessment
Regular Catheter Assessments are essential for patients with indwelling urinary catheters. This assessment ensures the catheter is still necessary, is clean and functional, shows no signs of deterioration, is properly secured with a fixation device, and that the drainage bag is within its expiry date. Routine catheter assessments help prevent infections and complications associated with catheter use.
Cubbin & Jackson Scale
The Cubbin & Jackson Scale is another pressure ulcer risk assessment tool, specifically designed for critically ill patients, often in intensive care settings. Similar to the Braden Scale and Waterlow Scale, it provides an estimated risk score for pressure sore development in this vulnerable population. Its focus on the critical care context makes it particularly relevant in ICUs.
Confusion Assessment Method (CAM)
The Confusion Assessment Method (CAM) is a standardized tool designed to help healthcare professionals identify delirium, or acute confusion, in patients. CAM uses specific criteria to assess for the presence of delirium, differentiating it from other forms of cognitive impairment. Early and accurate delirium detection with CAM is crucial for appropriate management and improved patient outcomes.
CAM-ICU
CAM-ICU is a modification of the Confusion Assessment Method specifically adapted for use in Intensive Care Unit (ICU) patients. ICU patients often present unique challenges for delirium assessment due to sedation, mechanical ventilation, and other factors. CAM-ICU addresses these challenges, providing a reliable delirium assessment tool tailored for the ICU environment. See RASS.
Centor Score
The Centor Score is a clinical decision rule used to estimate the probability of streptococcal pharyngitis (strep throat) in adult patients presenting with sore throat symptoms. It utilizes a set of criteria, including tonsillar exudates, swollen tender anterior cervical nodes, absence of cough, and history of fever. The Centor score helps clinicians determine the likelihood of bacterial infection and guide decisions regarding antibiotic treatment.
CRE Assessment
CRE Assessment refers to screening for Carbapenem-Resistant Enterobacteriaceae (CRE), a type of highly antibiotic-resistant bacteria. CRE assessments are crucial for infection control and prevention, particularly in healthcare settings. Identifying patients colonized or infected with CRE allows for implementation of appropriate isolation and infection control measures to prevent spread.
DisDAT (Distress in Dementia Assessment Tool)
DisDAT, or Distress in Dementia Assessment Tool, is specifically designed to identify and interpret signs of distress in individuals with cognitive impairment or physical illness who have limited communication abilities. It helps caregivers and nurses understand non-verbal cues indicating pain, discomfort, or emotional distress in patients who cannot express themselves verbally.
Early Warning Score (EWS)
Early Warning Scores (EWS), such as MEWS, NEWS, and PEWS, are scoring systems used to rapidly assess a patient’s overall physiological status and detect early signs of deterioration. These scores are based on vital signs including respiratory rate, oxygen saturation (SaO2), temperature, blood pressure, heart rate, and level of consciousness (AVPU/GCS). Some EWS systems also incorporate urine output. EWS facilitates timely intervention and escalation of care for patients at risk of worsening conditions.
FAST Assessment
FAST (Face, Arm, Speech, Time) is a widely recognized and easily remembered acronym used to assess for stroke symptoms. FAST helps quickly identify the key signs of stroke: Facial drooping, Arm weakness, Speech difficulty, and Time to call emergency services. Prompt recognition of FAST symptoms is critical for rapid stroke intervention and improved patient outcomes.
Falls Risk Assessment Tool (FRAT)
Falls Risk Assessment Tools (FRATs) are used to predict a patient’s likelihood of falling, both in hospital and home settings. FRATs consider various intrinsic and extrinsic risk factors, such as age, medication, mobility issues, and environmental hazards. Identifying patients at high risk of falls allows for implementation of preventative strategies to minimize fall-related injuries.
FRAX Tool
The FRAX tool (Fracture Risk Assessment Tool) was developed to evaluate an individual’s 10-year probability of hip fracture and major osteoporotic fracture. FRAX integrates individual patient risk factors, including age, bone mineral density, medical history, and lifestyle factors, to provide a comprehensive fracture risk assessment. This tool aids in identifying individuals who may benefit from interventions to prevent osteoporotic fractures.
FLACC Scale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a behavioral pain assessment tool specifically designed for pediatric patients and non-verbal adults who cannot self-report pain. FLACC assesses pain based on observed behaviors in five categories: Face, Legs, Activity, Cry, and Consolability. It provides a standardized and objective way to evaluate pain in populations unable to communicate verbally.
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) is a neurological scale used to objectively and reliably record the conscious state of a person. It assesses three components of consciousness: eye-opening response, verbal response, and motor response. The GCS score ranges from 3 (deep unconsciousness) to 15 (fully conscious), providing a standardized measure of neurological status for initial and ongoing assessments.
Glasgow Depression Scale for Learning Disabilities (GDS-LD)
The Glasgow Depression Scale for Learning Disabilities (GDS-LD) is specifically designed to assess mood and depression risk in individuals with learning disabilities. Standard depression scales may not be appropriate for this population. GDS-LD addresses the unique communication and cognitive considerations in assessing depression in people with learning disabilities.
Global Registry of Acute Coronary Events (GRACE) Score
The GRACE score (Global Registry of Acute Coronary Events) is a risk scoring system used in patients with acute coronary syndrome (ACS), including non-ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and unstable angina. The GRACE score helps clinicians estimate the risk of adverse cardiovascular events and guide treatment strategies in ACS patients.
Generalised Anxiety Disorder Questionnaire (GAD-7)
The Generalised Anxiety Disorder Questionnaire (GAD-7) is a 7-item self-report screening tool used to measure the severity of generalized anxiety disorder (GAD) symptoms. GAD-7 can be administered by healthcare professionals or self-completed by patients. It provides a quick and validated measure of anxiety symptom severity for screening and monitoring.
Hourly Rounding
Hourly rounding is a proactive nursing practice where nurses intentionally check on patients at least once every hour. It is particularly beneficial for patients who may be unable to call for help, such as those with dementia, delirium, or young children. Hourly rounding enhances patient safety and allows for timely identification and addressing of patient needs.
Hospital Anxiety and Depression Scale (HADS)
The Hospital Anxiety and Depression Scale (HADS) is a 14-item psychological screening tool used to assess anxiety and depression symptoms in both hospital and community settings. HADS is a widely used and validated tool for detecting and quantifying the severity of anxiety and depression in various patient populations.
Hs and Ts of Cardiac Arrest
The “Hs and Ts” is a mnemonic for the reversible causes of cardiac arrest. Identifying and addressing these underlying causes (Hypovolemia, Hypoxia, Hydrogen ion [acidosis], Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis [coronary or pulmonary]) is crucial in cardiac arrest management. The Hs and Ts guide a systematic approach to identifying and treating potentially reversible factors.
Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS)
The Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) is a self-assessment tool designed to measure side effects associated with antipsychotic medications. LUNSERS includes “red herring” questions to assess the accuracy of patient responses. It helps patients identify, understand, and become more aware of potential side effects they may be experiencing from antipsychotic drugs.
Manchester Triage System (MTS)
The Manchester Triage System (MTS) is a widely used triage system in emergency departments, particularly in the UK, Europe, and Australia. MTS assigns patients a priority level and a target time to be seen by a clinician based on their presenting complaint and clinical urgency. MTS ensures efficient and prioritized care delivery in busy emergency settings.
Malnutrition Universal Screening Tool (MUST)
MUST (Malnutrition Universal Screening Tool) is a five-step screening tool used to identify adults who are malnourished, at risk of malnutrition (undernutrition), or obese. MUST assesses BMI, unintentional weight loss, and acute illness effects on nutritional intake. It helps healthcare professionals identify individuals needing nutritional support or intervention.
Mini PAS-ADD (Psychiatric Assessment Schedule for Adults with Developmental Disability)
Mini PAS-ADD is a brief assessment tool specifically designed for conducting mental health assessments in individuals with learning disabilities. It is a shorter version of the PAS-ADD and focuses on key areas of mental health concerns in this population, facilitating more accessible and appropriate mental health evaluations.
Moving & Handling Assessments
Moving & Handling Assessments are crucial for ensuring the safety of both patients and healthcare staff during patient transfers and repositioning. These assessments determine the level of assistance, if any, required to safely mobilize patients, provide pressure area care, and perform other necessary tasks. Proper moving and handling techniques and assessments are essential for preventing injuries.
MRSA Assessment
MRSA Assessment (Methicillin-resistant Staphylococcus Aureus) is a risk assessment used to determine a patient’s risk of carrying MRSA. This assessment guides decisions about MRSA screening and decolonization measures if appropriate. Identifying MRSA risk helps prevent the spread of this antibiotic-resistant organism in healthcare settings.
Neonatal Pain, Agitation & Sedation Scale (N-PASS)
The Neonatal Pain, Agitation & Sedation Scale (N-PASS) is used primarily in neonatal intensive care units (NICUs) to assess pain, agitation, and sedation levels in infants. N-PASS evaluates behavioral cues and physiological responses to provide a comprehensive assessment in this vulnerable population.
PQRST Pain Assessment
PQRST (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing) is a mnemonic used to guide a comprehensive pain assessment. It helps nurses systematically explore the characteristics of a patient’s pain, including what makes it better or worse, the quality of the pain, where it is located, how severe it is, and its timing. PQRST provides a structured approach to pain assessment, aiding in diagnosis and treatment planning.
Two-Stage Capacity Test
The Two-Stage Capacity Test is a legal framework used to determine if an individual has the mental capacity to make a particular decision. Stage 1 assesses if there is an impairment or disturbance in the person’s mind or brain. Stage 2 determines if that impairment is significant enough to prevent the person from making a specific decision. This test is crucial for respecting patient autonomy and ensuring informed consent.
Traffic Light Assessment
The Traffic Light Assessment is a communication tool designed for children or patients with learning disabilities to express their likes, dislikes, and preferences to unfamiliar staff. It uses a simple color-coded system (red, yellow, green) to facilitate communication and ensure patient-centered care, especially for those with communication challenges.
Venous Thromboembolism (VTE) Assessment
Venous Thromboembolism (VTE) Assessments are used to evaluate a patient’s risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE). VTE assessments typically consider factors such as patient mobility, medical history, and surgical procedures. Identifying patients at high VTE risk allows for implementation of preventative measures like anticoagulation. See Wells Criteria.
Safer Nursing Care Tool (SNCT) / Acuity and Dependency Assessment
The Safer Nursing Care Tool (SNCT), also known as Acuity and Dependency Assessment, is designed to assess patient dependency levels and the nursing care hours required to ensure safe staffing levels. SNCT evaluates patient needs and care requirements to inform staffing decisions and resource allocation, promoting patient safety and quality care.
SBAR Communication Tool
SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication framework widely used in healthcare, including nursing. SBAR provides a structured approach to communicating patient information concisely and effectively, ensuring all essential details are conveyed during handovers, consultations, and other clinical communications. See ABCDE.
SBEAR Communication Tool
SBEAR (Situation, Background, Examination, Assessment, Recommendation) is a variation of the SBAR framework that includes an “Examination” component. SBEAR provides a slightly more detailed structure for communication, particularly when physical examination findings are relevant. See SBAR.
SPICT (Supportive & Palliative Care Indicators Tool)
SPICT (Supportive & Palliative Care Indicators Tool) is used to identify individuals at risk of deteriorating and dying from advanced conditions. SPICT helps healthcare professionals recognize patients who may benefit from palliative care and facilitates needs assessment and care planning in palliative care settings.
SOCRATES Pain Assessment
SOCRATES is a mnemonic acronym used to guide a detailed pain assessment. It stands for Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/Relieving factors, and Severity. SOCRATES provides a comprehensive framework for exploring and documenting the nature of a patient’s pain experience.
Richmond Agitation-Sedation Scale (RASS)
The Richmond Agitation-Sedation Scale (RASS) is a sedation scale used to assess a patient’s level of agitation or sedation. RASS is one of several sedation scales used in medicine, including Ramsay Scale and Sedation-Agitation Scale. It provides a standardized measure of sedation level, particularly important in critical care settings. See CAM-ICU.
Waterlow Scale
The Waterlow Scale is another pressure ulcer risk assessment tool, similar to the Braden Scale. It assesses various risk factors to predict a patient’s likelihood of developing pressure ulcers. See Braden Scale.
WHO Surgical Safety Checklist
The WHO Surgical Safety Checklist is a tool designed to improve patient safety in surgical settings. It reinforces accepted safety practices and promotes better communication and teamwork among surgical teams. The checklist includes sections for team introductions, patient identity verification, and confirmation of the planned procedure and consent.
Wong-Baker FACES Pain Rating Scale
The Wong-Baker FACES Pain Rating Scale is a visual pain assessment tool that uses a series of faces depicting different emotions to represent varying levels of pain intensity. It is particularly useful for children and individuals who may have difficulty expressing pain verbally.
Wells Criteria
Wells Criteria are clinical decision rules used to assess the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE). Wells Criteria help clinicians estimate the likelihood of these conditions based on clinical findings, guiding decisions about diagnostic testing and treatment. See VTE Assessment.
Visual Infusion Phlebitis Score (VIPS)
The Visual Infusion Phlebitis Score (VIPS) is a tool used to assess and grade phlebitis (inflammation of a vein) associated with peripheral intravenous catheters. VIPS helps nurses monitor IV sites for early signs of phlebitis and facilitate timely removal of catheters to prevent complications.
