Health Assessment Hacks

Recall that the first step of the nursing process is Assessment. Being able to collect data is fundamental to your success as a nurse. You want to be as organized, systematic, and of course, as accurate as possible. 

Quickly make an accurate and organized assessment with our Health Assessment Hacks. 

Level of Consciousness – AVPU 

This scale is a simplified version of the Glasgow Coma Scale and measures patient response through eyes, voice, and motor skills. How responsive a patient is indicates their level of consciousness. For each measure, there are 4 possible identifiable traits from best (A) to worst (U). Note that AVPU is not intended to indicate long-term neurological status. 

	ADULT	PEDIATRIC
ALERT	Eyes open spontaneously and track people and objects Patient appears aware of & is responsive to the environment Patient can follow commands	Child is active and responds appropriately to SO and other external stimuli
VOICE	Eyes do not open spontaneously but open in response to verbal stimuli Able to respond in some meaningful way when spoken to	Child responds only when his/her name is called by SO
PAIN	Does not respond to questions but moves or cries out as a response to painful stimuli (i.e., pinching skin or earlobe)
UNRESPONSIVE	Patient does not respond to any stimuli

Health History – SAMPLE 

SAMPLE is a common mnemonic for remembering key elements of a patient’s health history. Remember that a detailed history should not be obtained if the patient is sustaining life-threatening injuries. These should be prioritized and addressed with appropriate therapy. Assess progress and vital signs afterwards with this memory tool. 

SYMPTOMS	Patient’s chief complaints	“What’s wrong?” “What brings you to the hospital?”
ALLERGIES	Allergic reactions the patient experiences	“Do you have any known allergies?” “What typically happens to you when you come in contact with something you’re allergic to?”
MEDICATIONS	Prescribed, OTC drugs, herbal medicines, etc.	“Are you taking any medications?” “What are you taking these for?” “When did you last take your medication?”
PAST MEDICAL HISTORY	Previous state of health, previous illnesses	“Have you had this problem before?” “Do you have any medical problems/conditions?”
LAST ORAL INTAKE	Last meal or drink	“When was the last time you ate or drank something?” “What was the last thing you ate or drank something?”
EVENTS	Events that led up to illness or injury	“How did you get hurt?” “What led to this problem?”

Rapid Trauma – DCAP-BTLS

DCAP-BTLS is used to remember specific soft tissue injuries that a healthcare professional should note when assessing a patient post-traumatic injury. 

DEFORMITY & DISCOLORATION	Malformations or distortions of the body
CONTUSION	Injury to tissues with skin discoloration; without breakage of skin (a.k.a. a bruise)
ABRASION	Scrape used by rubbing from a sharp object resulting in denuded surface of skin
PUNCTURE OR PENETRATION	Wound with relatively small opening compared with the depth; produced by a narrow pointed object
BURN	Injuries to tissue caused by heat, friction, electricity, radiation, or chemicals
TENDERNESS	Sore to the touch
LACERATION	A torn or jagged wound caused by blunt trauma; often incorrectly used to describe a cut
SWELLING	Sign of inflammation; caused by exudation of fluid from the capillary vessels into the tissue

Alcoholism – CAGE

The CAGE questionnaire is a widely accepted method for alcoholism screening, wherein 2 “yes” responses indicate possible alcoholism. This means the patient should undergo further screening. Many clinicians use even just 1 “yes” response to the EYE OPENER question as a positive to the CAGE questionnaire. 

Concern by the person that there is a problem	Have you ever felt that you should cut down on your drinking?
Apparent to others that there is a problem	Have you ever become annoyed by criticisms of your drinking?
Grave consequences	Have you ever felt guilty about your drinking?
Evidence of dependence or tolerance	Have you ever had a morning eye opener to get rid of a hangover?

Emergency Trauma – ABCDEFGHI

The ABCDEFGHI mnemonic is a quick assessment tool for trauma patients. This can be especially life preserving in emergency cases. It is able to identify areas that require more attention and immediate action by the rescuer. 

Primary Survey
AIRWAY	Ensure that the airway is open for proper oxygen intake and removal of carbon dioxide. Use head-tilt chin-lift technique to open the airway. Check for and remove all obstructions.
BREATHING	Observe the patient’s chest for the rise and fall of normal respiration. Listen for air movement and feel for air coming through the mouth/nose. If there is abnormal or no breathing at all, initiate CPR with 2 breaths.
CIRCULATION	Check the patient’s pulse to determine if CPR is needed. Breathing must be present for circulation of oxygen-rich blood.
Secondary Survey
DISABILITY	Assess the patient for neurological status and for obvious deformities or disabilities.
EXPOSE & EXAMINE	Remove clothing as necessary to properly
FULL SET OF VITAL SIGNS	Note any changes in the following: pulse (carotid, brachial, radial), pupils, breathing, level of consciousness, blood pressure, skin color, temperature
GIVE COMFORT MEASURES	Continue to rest and reassure
HISTORY AND HEAD-TO-TOE ASSESSMENT	Use the SAMPLE mnemonic above
INSPECT POSTERIOR SURFACE	Inspect posterior surface for wounds, deformities, discolorations, etc.

Seven Warning Signs of Cancer – CAUTION 

Fundamental to the treatment of cancer is early detection. The American Cancer Society offers the CAUTION mnemonic to help in recognizing the early warning signs of the disease. Note that just because a patient presents with one of these signs, this is not to mean they have cancer. 

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Family History – BALD CHASM

The mnemonic BALD CHASM is meant to help you recall diseases that should be investigated when taking a patient’s family history. After all, family history plays a big role in the assessment of inherited medical conditions, chronic illnesses, and genetically-transmitted diseases. Make sure to take note of the age & health status, or age & cause of death of siblings, parents, and grandparents. 

B	Blood pressure
A	Arthritis
L	Lung disease
D	Diabetes
C	Cancer
H	Heart disease
A	Alcoholism
S	Stroke
M	Mental health disorder

Breast – LMNOP

All breast masses should be properly evaluated so that diagnosis can be done and treatment initiated if necessary. Breast masses have various etiologies, from fibroadenomas to cysts, to abscesses, mastitis, to breast cancer. 

LUMP	Inspect and palpate for any lump or mass
MAMMARY CHANGES	Inspect and palpate for dimpling, tenderness, abnormal contour
NIPPLE CHANGES	Inspect and palpate for nipple retraction, lesions, discharge
OTHER SYMPTOMS	Check size, symmetry, appearance of skin, direction of pointing, rashes, and ulceration
PATIENT RISK FACTORS	Interview the patient for predisposing factors, obtain family history, or use the Breast Cancer Risk Assessment Tool

Eyes

Abbreviations used for the eyes typically employ the Latin terms. OU is ‘Oculus Uterque’ meaning both eyes. OD is ‘Oculus Dexter,’ pertaining to the right eye. OS stands for ‘Oculus Sinister,’ which pertains to the left eye. The following phrases might help you remember these abbreviations with more ease: 

YOU look with both eyes. 

The right dose won’t OD. 

The only one left is OS. 

Signs vs. Symptoms 

Lots of students continue to confuse the difference between signs and symptoms. Signs are objective and observed by the healthcare professional performing an examination on a patient. On the other hand, symptoms are reported by the patient and cannot typically be measured. 

SIgn is something I can detect even if a patient is unconscious. 

SYMptom is something only hYM knows about. 

Pain – OPQRSTU

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage. It is subjective and warrants careful assessment and evaluation. Pain assessment is a crucial part of delivering care; nurses should pay close attention to it when carrying out therapy. 

ONSET	When did it begin? How long does it last? How often does it occur? What were you doing when the pain began?
PROVOKING OR PALLIATING FACTORS	What brings the pain on? What makes it better? What makes it worse?
QUALITY	What does it feel like? Can you describe the sensation (throbbing, stabbing, dull, etc.)?
REGION & RADIATION	Does your pain radiate? Where does it spread to? Point to where it hurts the most. Where does your pain go from there?
SEVERITY	What is the intensity (pain scale of 1-10, visual scales) of the symptom? Right now? At its worst? Are there any symptoms that accompany the pain?
TIME & TREATMENT	When did the symptoms first begin? What medications are you currently taking for this? How effective are these? Any side effects?
UNDERSTANDING & IMPACT	What do you believe is causing this? How is this affecting your activities of daily living (ADLs), you, and/or your family?
VALUES	What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom? Do you have any other concerns?