‘Tools of the Trade’: Adult Field

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.

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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

Frailty Assessment

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?
2- Male?
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.

A- Alert
V- Alert to Voice
P- Alert to Pain
U- Unconscious 

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.

Waterlow Scale

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.

waterlow score card

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.

 

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Tools of the Trade – Mental Health Nursing

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Assessment or screening tools are key to gathering a whole wealth of information from a client and they can often lead to them opening up about other or underlying issues that may be impacting on their health. How and what they answer can give you insight into their current feelings about things as well as provide a baseline of presentation to record any future changes and used to point towards treatment required. Being able to monitor someone’s recovery progress can help staff encourage and motivate a person, just as being able to monitor someone’s deterioration can help staff adapt treatment and interventions appropriately.

Tools are not always perfect and we have to work with them openly and carefully using them as a guideline to help support the treatment or diagnosis we provide. Below is a short list of the some of the assessment tools you might come across on placement;

The Hospital Anxiety and Depression Scale (HADS) – Used for Anxiety & Depression can be used in community as well as hospital. It is a 14 question Psychological screening tool assessing the severity of symptoms.

Generalised Anxiety Disorder Questionnaire (GAD-7) – Screening tool used to measure the severity of Generalised Anxiety Disorder. 7 questions that can be administrated by a health care professional or self-administrated by the client themselves.

The Mini Mental State Examination (MMSE) – Commonly used short assessment used for screening for any dementia or cognitive impairment concerns are suspected. It measures cognitive functioning, and can be used to monitor change. 11 item tool taking around 10 minutes to administer making it a quick and useful tool to use.

The Addenbrooke’s Cognitive Examination (ACE) –  Well validated assessment tool for clinic setting assessment of cognitive functioning. This measures cognitive domains including language, visuospatial, memory and attention.  Usage is usually in part with other screening tests such as blood test, ECG and MRI scan to inform a diagnosis.

The Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) – Is a self-assessment tool for measuring the side-effects of antipsychotic medications. Red herrings are included to check the accuracy of the results. The 51 questions are based on true side effects with 10 being false  ones aim to help patients Identify, understand and gain awareness of side effects they could be experiencing.

The Alcohol Use Disorders Identification Test (AUDIT) – A basic screening tool used to pick up the early signs of hazardous and harmful drinking and identify mild dependence and highlight if a need for assisted withdrawal is required.

There are many varied tools assessing risk used by health care professionals in all fields and in  a wide variety of settings. It is important practitioners should take care to always explain what is involved,  how long it will last and how they can help a patient and their treatment.

Using an assessment tool can help uncover more information about a patients situation and help to encourage conversation that could provide valuable information to inform their care is more personalised and help reduce risk.

Keep your assessment tool box handy and help patients access all areas in health care support.smile

Week 2 – DILP Questions Answered!

At the end of my second week working in a Sri Lankan hospital I am pretty exhausted. It’s been a really full on week; my first ever in A&E and it’s been absolutely invaluable. I’ve observed lots of amazing Nursing and care but can’t seem to keep myself from thinking “Oh, that’s not how we do it in England” every time something surprises me.

IMG_7797.JPGAfter last week’s post a few of you had some questions about the DILP and how myself and others went about it. Since I have organized my placement independently I referred to my friends currently working in Andhupura who have gone through Work the World for their DILP about their experiences too. They explaned that they chose Andhupura because it seemed to have a richer culture compared to Kandy and was near the beaches of Trincomalee which is one of Sri Lanka’s best preserved pieces of coast-line with clear blue waters and lots of snorkeling opportunities.

Firstly and often most crucially going abroad for this placement is an expensive undertaking. Going through an agency condenses all the costs however into one lump sum you pay directly to them to organize accommodation, flights etc. this can be paid in installments or in one go but the deadline is a couple of months before you fly. It has been known for people to fundraise to pay for their DILP but none of the lovely Ladies in Andhupura did but we were told by the DILP unit lead to expect to pay around £3000 through an Agency so fund raising may be a very good option.

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Our ECG machine – complete with metal suction cups

Since I organized mine independently it cost a lot less, around £1500 for flights, accommodation, visa’s, insurance and the cost of living whilst I’m here. Although recommending someone to go it alone abroad is much like recommending someone to do a home birth without alerting a midwife. It can be super rewarding and great but if something goes wrong – it can be really disastrous.

Work the World have been really wonderful with all the students who worked with them, really helpful and easy to contact which made the whole process very straightforward and stress-free. Also the students (who come from all over and include OTs and Medics) with Work the World all stay near to eachother which is nice to have a little support hub of people all going through the same thing.

People were curious about time off and whether or not we have the ability to actually experience the country and the culture whilst working 37.5 hours a week. We were unanimous in our answer of YES!! 7.5 hours a day with early starts does mean it’s not advisable to be staying up late every night having cocktails at a beach bar but there is always the weekends for that!

I’ve been working 8 hour shifts (excl. breaks) 7-3.30 each day which leaves me a big chunk of the afternoon to do as I please. With a coupe of 12 hour night shifts thrown in I’m finishing placement in 6 weeks (30 days) as opposed to the 7 weeks (33 working days excl. bank holidays) allocated by the university. This means I’ll have a week at the end of my placement exclusively for free time.

I’m lucky enough to be able to stay on for a while after placement is done to travel around the island a bit and holiday with my family and boyfriend which is a really nice goal to aim for when I’m missing home.

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“Difficulty walking, slurring speech, brain stem stroke”

The language barrier can be frustrating at times but all medical terms are spoken and written in English so you can spot quite easily what each case is about. Most of the Nurses I’ve encountered have a good grasp of English so if you ask questions, they will try their hardest to explain. The best thing about working abroad is the independence. You are relying on your Nursing instincts and knowledge, I’ve learnt a lot from my mentors and patients but I have taught them a lot as well. I’ve introduced a new standardized handover tool, which has been saving hours of staff time. I’ve been screenshot-ing and explaining tools such as the Bristol Stool Chart and the SBAR in an effort in increase the use of evidence based assessment tools. The staff are really keen to learn as am I which makes for a really engaging and exciting atmosphere in the ward.

Again any more questions you have about working abroad, working independently or the DILP in general please do comment on our Facebook page or email us at enhancingplacement@gmail.com