Preparing for your first placement and feeling uncertain about what assessment tools you might encounter? Have a browse through this post where we’ve collated some assessment tools and tips you might find useful, with links to the sources in the title. If you’ve not seen it already, you can also find some useful information in our top tips album on our Facebook page. Have a look at the Mental Health tips and tools here, Child Field and Midwifery specific posts to follow soon!
Below are a selection of assessment tools in alphabetical order, remember that all risk assessment scoring tools are simplified to some extent and scoring may be subjective. Therefore it’s important to use them in the correct setting alongside your own clinical judgement, never underestimate your gut feeling and if you have any concerns about a patient, speak up!
Bristol Stool Chart
Also known as the Meyers scale, the pictures and descriptions on the Bristol stool chart will help you assess stool samples. Stool charts are often in place if a patient is being barrier nursed with infective diarrhoea. Colour, presence of blood or mucus are also important things to look out for when assessing stool samples.
ECOG Performance Status Score
Used in Oncology to assess disease progression and how this impact’s on a patient’s activities of daily living. Created by the Eastern Cooperative Oncology Group, this 0-5 scale is something you will come across on any oncology placements, familiarising yourself with the descriptions of these categories will help you understand the impact of performance status on patient’s day to day experiences.
Grade 0 : Fully active, able to carry on all pre-disease performance without restriction
Grade 1 : Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
Grade 2 : Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours
Grade 3 : Capable of only limited self care, confined to bed or chair more than 50% of waking hours
Grade 4 : Completely disabled, cannot carry on any self care, totally confined to bed or chair
Grade 5 : Dead
There are many different tools used to assess frailty, but the PRISMA 7 checklist below is perhaps the easiest to use as an informal prompt to identify at risk patients. It has been used in a variety of research studies on frailty to identify disability, a score of >3 indicates frailty.
1- Older than 85 years?
3- Any health problems which limit ADLs?
4- Requiring help on a daily/regular basis?
5- Housebound due to health conditions?
6- In case of need can they count on someone close to them?
7- Regular use of a stick, walker, wheelchair or other aids to get about?
Other red flags to look out for include is a patient lives alone or if they are a carer for another person. Frailty can impact on discharge planning and is useful to consider when planning interventions to avoid future hospital admissions. There are also other useful resources and information from Age UK and the British Geriatrics Society.
Glasgow Coma Scale (GCS)
GCS is used to assess a patients consciousness level, primarily in acute areas such as A&E or ICU. Assessing a patient’s GCS can be complex and involves three categories: eye opening, verbal response and best motor response. After checking for factors that might impede the patient’s ability to respond, each of the three criteria are assessed through observation and stimulus and are then rated according to the highest observed response. Unless you’re working in a placement are which uses the GCS assessment frequently where you can be taught how to use it correctly, it’s probably best to use an alternative.
AVPU is a similar tool to rapidly and simply assess your patient, it is based on the same three categories as the GCS and looks for the best response, working down from best to worst A-U to avoid unnecessary tests.
V- Alert to Voice
P- Alert to Pain
If a patient is fully awake and can spontaneously open their eyes and has control of motor function they are Alert, although they do not necessarily have to be orientated. Patients who are alert to Voice will make some form of response in any of the three categories when you speak to them. If alert to Pain, a patient with some level of consciousness will respond to painful stimuli with any of the same categories of response and fully unconscious patients will form any response to any of the above.
Early Warning Score (EWS)
In practice you may come across some variations of the EWS (Paediatric (PEWS), Modified (MEWS), National (NEWS) and Modified Early Obstetric Warning Score (MEOWS)), for this reason the scores and corresponding clinical observations haven’t been included in this post.
Ensure you use the tool that has been selected for use in your clinical area as there are variations between them according to specific patient type or to support best evidence based practice. To begin with don’t worry about remembering the exact scores for each observation, the scores are printed on observation charts and care plans, all you need to recognise is when observations are abnormal and escalate it.
When taking a full set of observations, a score is given based on how far they deviate from a normal baseline. These are then added together to produce an overall score. The higher the score, the more severe the level of clinical deterioration. Research has shown that scores of 5 of higher are linked to increased ICU admission and mortality.
The idea behind EWS is that a deterioration will be flagged up by a score which can then be acted on before the patient deteriorates further. However in practice a patient may go off quickly where their previous score may have been within the normal parameters, be wary when a patient’s overall score may well be zero but when charted you notice that their observations are borderline and if one figure higher would then begin to score. In situations like this it may be prudent to recheck their obs to ensure a correct reading or to increase the frequency of repeating their observations.
It’s also wise not to underestimate the importance of using your clinical judgement in conjunction with good communication with your patient. For instance, don’t dismiss a “feeling of impending doom” reported by your patient, it can have high clinical significance. As before, if you have any concerns about a patient, make sure you escalate them to a member of staff.
The Malnutrition Universal Screening tool (MUST)
MUST is an accredited screening tool from the British Association of Parenteral and Enteral Nutrition (BAPEN), whose aim is to improve management and understanding of malnutrition.
You can use this tool to obtain a score and risk category for the patient and create an action plan. A MUST assessment is generally completed on admission to any inpatient area and for low risk patients is usually repeated weekly. For patients with a higher risk of weight loss and malnutrition this is reassessed more frequently according to level of risk to check the efficacy of any interventions that have been implemented.
To help you complete a MUST assessment, you can find the NHS BMI calculator here and the metric-imperial conversion chart is below.
Developed by Judy Waterlow, a clinical nurse teacher, in the 1980s; the Waterlow scale is used to assess the risk of pressure damage or pressure ulcers forming. These ulcers are formed through pressure, friction or shearing forces; usually on prominent bony surfaces causing damage to the underlying tissue and skin.
Once formed, pressure ulcers can be very problematic to treat and slow to heal so prevention is better than cure! Good manual handling technique to avoid friction and shearing and regular turning for pressure relief and/or use of mattress aids is key to avoiding ulcer formation.
The tool below shows scoring tables for different risk categories to create and overall score. Special risks for consideration are shown in the pink box, such as time spent immobile on an operating table or neurological conditions affecting mobility and therefore patients’ own ability for independent pressure relief.
To understand more about pressure ulcers you may want to consider a spoke with the Tissue Viability nurses, most wards will also have a tissue viability link nurse who you could speak to.