Nursing HEalth Assessment Mnemonics

But with the many ways to assess a patient, assessment has become an overwhelming process. To be
more systematic, here are nursing health assessment mnemonics & tips you can use to accurately and
quickly assess variety of patients in with different conditions and in various situations.

1. Level of Consciousness Assessment: AVPU

The AVPU scale is a system where you can measure and record a patients responsiveness to indicate their
level of consciousness. It is a simplification of the Glasgow Coma Scale, which assesses a patient response
in three measures: eyes, voice, and motor skills. The AVPU scale should be assessed during these three
identifiable traits, looking for the best response for each. It has four possible outcomes for recording and the
nurse should always work from best (A) to worst (U) to avoid unnecessary tests on patients who are clearly
conscious. On the other hand, it should not be used for long-term follow up of neurological status.

A: Alert

V: Response to Verbal Stimuli

P: Response to Pain

U: Unresponsive

2. Health History Assessment: SAMPLE

In general, do not obtain a detailed history until life-threatening injuries have been identified and therapy has
been initiated. The secondary survey is essentially a head-to-toe assessment of progress, vital signs, etc.
SAMPLE is often useful as a mnemonic for remembering key elements of the patients health history.

S: Symptoms

A: Allergy

M: Medications

P: Past Medical History

L: Last Oral Intake

E: Events leading up to the illness or injury

3. Rapid Trauma Assessment: DCAP-BTLS

DCAP-BTLS is a mnemonic to remember specific soft tissue injuries to look for during assessment of a
person after a traumatic injury.

D: Deformities

Malformations or distortions of the body.

C: Contusions

Injury to tissues with skin discoloration and without breakage of skin; also called a bruise.

A: Abrasions

Scrape caused by rubbing from a sharp object resulting in surface denuded of skin.

P: Punctures or Penetrations

Wound with relatively small opening compared with the depth; produced by a narrow pointed
object.

B: Burns

Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals.

T: Tenderness

The condition of being tender or sore to the touch.

L: Lacerations

A torn or jagged wound caused by blunt trauma; incorrectly used when describing a cut.

S: Swelling

Sign of inflammation; caused by the exudation of fluid from the capillary vessels into the tissue.

4. Alcoholism Screening: CAGE

CAGE questionnaire is a widely used and an extensively validated method of screening for alcoholism. Two
yes responses indicate that the possibility of alcoholism should be investigated further. By far the most
important question in the CAGE questionnaire is the use of a drink as an Eye Opener, so much so that some
clinicians use a yes to this question alone as a positive to the questionnaire; this is because the use of an
alcoholic drink as an Eye Opener connotes dependence since the patient is going through possible
withdrawal in the morning, hence the need for a drink as an Eye Opener.

C: Have you ever felt that you should CUT down on your drinking?

A: Have you ever become ANNOYED by criticisms of your drinking?

G: Have you ever felt GUILTY about your drinking?

E: Have you ever had a morning EYE OPENER to get rid of a hangover?

5. Emergency Trauma Assessment: ABCDEFGHI

The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for
emergency cases. The purpose of primary assessment is to preserve the life of the victim, taking action
where needed. Once the victims life-threatening conditions have been address, the rescuer must begin
secondary assessment.

A: Airway

Keep the airway open to allow the body to take in oxygen and expel carbon dioxide. Use the
head-tilt chin-lift technique to open the airway. Check or and remove obstructions. A blocked
airway can lead to respiratory or cardiac arrest.

B: Breathing

Once the airway is open, check for normal breathing, make use of the look, listen, and feel
techniques.

Look at the chest and observe the rising and falling for normal respiration. Listen for air
movement. Feel for air coming through the mouth or nose. If there is no breathing or abnormal
breathing, CPR must be initiated with 2 breaths.

C: Circulation

Oxygen-rich blood cannot be circulated without breathing. Hence, its unnecessary to check for
pulse to determine whether CPR is needed; commence immediately if no breathing is detected.

D: Disability

Check the patients neurological status and for obvious deformities or disabilities.

E: Expose & Examine

Remove clothing to properly assess patient; be sure to keep the patient warm.

F: Full set of vital signs

Note any changes in the following signs: pulse (carotid, brachial, radial), pupils, breathing, level
of consciousness, blood pressure, and skin color and temperature.

G: Give comfort measures

Continue to rest and reassure. Provide comfort measures and prevent further injury.

H: History and Head-To-Toe Assessment

Use the mnemonic SAMPLE to obtain health history and do a head-to-toe assessment after.

I: Inspect Posterior Surface

Inspect for wounds, deformities, discolorations, etc.

6. Seven Warning Signs of Cancer: CAUTION

Early detection is the key in treatment of cancers. The CAUTION mnemonic is used by the American Cancer
Society to detect and recognize the early warning signs of cancer. Though one of these signs does not
necessarily mean someone has cancer.

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

7. Family History Assessment: BALD CHASM

Family history plays a critical role in assessing the risk of inherited medical conditions, chronic illnesses and
genetically transmitted diseases. Outline or diagram age and health, or age and cause of death of siblings,
parents, and grandparents. Document presence or absence of specific illnesses in family. Use the
mnemonic BALD CHASM to recall the diseases that needs to be investigated.

B: Blood pressure

African Americans have a higher risk for high blood pressure. Poor lifestyle choices and diet,
that can be inherited by the family, can also pose as a risk.

A: Arthritis

Some types of arthritis run in families. Genes can be a contributing factor that can make
someone susceptible to environmental factors that may trigger arthritis.

L: Lung diseases

Cystic fibrosis is a common inherited disease that affects mostly the lungs. It is manifested by
accumulation of thick, sticky mucous, frequent infections and coughing.

D: Diabetes

History of type 2 diabetes in the family poses the patient at increased risk of developing it.

C: Cancers

Certain types of cancer, such as breast cancer and colon cancer, appear more frequently in
some families.

H: Heart diseases

Genes can pass on the risk of cardiovascular disease, and they can also be responsible for
passing on other conditions such as high blood pressure or high cholesterol levels.

A: Alcoholism

Certain genetic factors influence alcoholism. Research show that children of alcoholics are
about four times more likely than the general population to develop alcohol problems.

S: Stroke

Risk for stroke is higher if someone in the patients direct family line that stroke. Some strokes
may be symptoms of genetic disorders like CADASIL.

M: Mental health disorders (depression, bipolar, schizophrenia etc.)

Some mental illnesses can run in families, although it may be from variety of factors rather than
just genes.

8. Breast Assessment: LMNOP

Breast masses show marked variation in etiology, from fibroadenomas to cysts, to abscesses, mastitis, to
breast cancer. All breast masses warrant careful evaluation, and definitive diagnostic measures should be
pursued.

L:Lump

Inspect and palpate breast for lumps, masses

M: Mammary changes

Inspect and palpate for dimpling, tenderness, abnormal contours

N: Nipple changes

Inspect and palpate for nipple retraction, lesions, discharges.

O: Other symptoms

Check size, symmetry, appearance of skin, direction of pointing, rashes, and ulceration

P: Patient risk factors

Interview patient for predisposing factors, obtain family history or use the Breast Cancer Risk
Assessment Tool.

9. Eyes Abbreviation
Abbreviations for the eyes are often confusing. OU which stands for the latin term Oculus Uterque means
both eyes; OD for Oculus Dexter referring to the right eye and OS for Oculus Sinister for the left eye.
Remember the mnemonic above to make sense of these abbreviations.

YOU look with BOTH eyes.

The RIGHT dose wont OD [overdose].

The only one that is LEFT is OS.

10. Signs VS Symptoms

Signs are commonly distinguished from symptoms and both are something abnormal and relevant to a
potential medical condition. A sign is objective and is discovered by the health-care professional during an
examination whereas a symptom is subjective, observed and experienced by the patient, and cannot be
measured directly.

sIgn: something I can detect even if patient is unconscious.

sYMptom is something only hYM knows about.

11. Pain Assessment: OPQRSTU

Assessment of pain is a crucial part in the role of nurses, and as such utilizing a problem-solving process
becomes part of the equation. Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of damage. Pain is subjective thus a careful
assessment and evaluation is needed.

O: Onset

When did it begin? How long does it last (duration)? How often does it occur (time)? What were
you doing when the pain started?

P: Provoking or Palliating Factors

What brings it on? What makes it better? What makes it worse?

Q: Quality

What does it feel like? Can you describe it (throbbing, stabbing, dull, etc.)?

R: Region & Radiation

Does your pain radiates? Where does it spread? Point to where it hurts the most. Where does
your pain go from there?

S: Severity

What is the intensity (pain scale of 1-10, visual scales) of the symptom? Right now? At worst?
Are there any other symptoms that accompany the pain?

T: Time & Treatment

When did the symptoms first begin? What medications are you currently taking for this? How
effective are these? Side effects?

U: Understanding & Impact

What do you believe is causing this? How is this affecting your ADLs, you and/or your family?

V: 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?