They say that the best nurses are excellent at obtaining assessments, and this is true! If nurses would look at the nursing process, assessment is the first and key step. Gathering information about the patient will provide clues for what care you can give and what you can intervene. If you have a weak foundation in assessment, the rest of the process follows. One way to help retain nursing information is through the help of nursing mnemonics.
To be more systematic, here are some nursing mnemonics and tricks (assessment and nursing skills) you can use to accurately and quickly assess a variety of patients in different conditions and in various situations.
1. A SAMPLE health history
SAMPLE, a mnemonic or memory device, is used to gather essential patient history information to diagnose the patient’s complaint and make treatment decisions. Asking the below SAMPLE questions and taking nursing notes is the start of a conversation between you, the investigator, and the patient, your research subject.
- Symptoms – a sign or symptom is something you as a first-aid provider observe or record.
- Allergies – ask if the patient has ever had any allergic reactions to any medications. Also enquire about environmental allergies, for example, food and insect stings.
- Medications – ask if the patient takes any prescription medicines. This can sometimes give you an indication of a possible medical problem and a new line of questioning.
- Past medical history– ask about relevant medical history. Obtaining an in-depth history may sometimes not be necessary but information such as two heart attacks last year and a coronary bypass three weeks ago is essential.
- Last oral intake – ask about the patient’s last intake of food and drink, this is especially important if the condition could be caused by food or drink.
- Events preceding injury – the final questions are an opportunity for the patient to give you a frame-by-frame description of what happened leading up to their illness or injury.
Watch the following video to know – SAMPLE history
2. The nursing process – ADPIE
The ADPIE (A Delicious PIE) process helps medical professionals remember the process and order of the steps they need to take to provide proper care for the individuals they are treating. This process is important as it provides a useful and throughout framework in the patient care for developing critical thinking and problem-solving skills. The steps in your nursing care plan may be remembered with the mnemonic ADPIE.
- Assessment – during the assessment phase, you will attempt to identify the problem and establish a database by interviewing the individual and/or family members, observing their behavior, and performing examinations.
- Diagnosis – the diagnosis phase of the process is the phase where you will develop a theory or hypothesis about the individuals’ situation based on the information that has been collected while performing an assessment.
- Planning – is the process of developing a plan and establishing SMART goals in order to achieve the desired outcome such as reducing pain or improving cardiovascular function.
- Implementation – the implementation phase of the process is the actionable part of the process where the individual and medical team implement the care plan, SMART goals, and interventions so that the individual can achieve their goals and the process can be evaluated and measured.
- Evaluation – is the part where nurses assess and evaluate the success of the planning and implementation processes to ensure that the individual is making progress towards his/her goals and is achieving the desired outcome.
Watch the following video to know – ADPIE: the nursing process
3. Auscultation of heart sounds
There are two important reminders in auscultating heart sounds – the S1 or the first heart sound is loudest at the apex of the heart while S2 sounds or the second heart sounds are loudest at the base of the heart.
The S1 results from the closing of AV valves and this is the reason why it can be heard loudest at the base of the heart. The S2 sounds result from the closure of semilunar valves and these sounds can be heard prominently at the apex of the heart.
Watch the following video to know – how to hear S1 and S2 heart sounds
4. Emergency trauma assessment
During emergency trauma accidents, proper assessment can be easily remembered with the alphabetical letters A-I as they are the important nursing skills required for the emergency room.
- Airway – check for patency of the airway. Make sure that there is no obstruction along the airway passages.
- Breathing – is the patient still breathing? Check for the quality of breathing pattern if it’s too fast or to shallow.
- Circulation – checking for the pulse, heart rate and blood pressure will ensure if the blood circulation within the body is not compromised.
- Disability – check if the patient can fully move his limbs. Check the five senses – vision, hearing, smell, taste, and touch. Assess the level of consciousness of the patient if he is fully awake and oriented.
- Examine – visually examine the patient for problems. Look for wounds, fractures, and other physical problems.
- Fahrenheit – check the patient’s temperature if there is hyperthermia or hypothermia.
- Get Vitals – obtain the patient’s vital signs like temperature, heart rate, respiratory rate, and blood pressure.
- Head-to-toe assessment – conduct a physical assessment from head-to-toe. Determine body symmetry.
- Intervention – for the problems detected after completing your assessment, prioritize planned interventions. Conducting first-aid interventions is beneficial before transferring the patient into proper medical facilities.
Watch the following video to know – trauma ABCDEFGHI nursing mnemonics
Hyperkalemia is a condition where there is an abnormally high level of potassium in the blood. Signs and symptoms that should be observed when assessing a patient for hyperkalemia include muscle cramps, muscle twitches, paresthesias, irritability, decreased blood pressure, ECG changes, dysrhythmias, abdominal cramps, and diarrhea.
ECG readings of patients with hyperkalemia will reveal a prolonged PR segment, flat P, widened QRS segment, peaked T, and depressed ST segment.
Watch the following video to know – electrolytes hyperkalemia nursing mnemonics
Hypokalemia is a condition where there is an abnormally low level of potassium in the blood which starts with L. So the 6 L’s (Lethargy, Leg cramps, Limp muscles, Low shallow respirations, Lethal cardiac dysrhythmias, Lots of urine ) can help you recognize the signs and symptoms of low potassium or hypokalemia. Changes in ECG may also be observed where there will be an abnormality in the QRS segment.
Watch the following video to know – hypokalemia 6 L’s nursing mnemonics
7. Lead II placement
Lead II placement can be easily remembered with the mnemonic salt, pepper, and ketchup. The white lead should be placed in the right part of the chest while the black lead is in the left part of the chest.
Watch the following video to know – ECG lead placement BEEP nursing mnemonics
8. Levels of consciousness
The AVPU mnemonic is a mnemonic used by first aiders in quickly assessing the level of consciousness of the patient.
- Alert – the patient is fully awake and opens the eyes spontaneously.
- Voice – the patients’ response to verbal stimuli or only when you talk.
- Pain – the patient only responds when a painful stimulus is elicited. The sternal rub and squeezing of the fingers are the two most commonly used painful stimuli in assessing the level of consciousness.
- Unresponsive – also known as unconscious, the patient is considered unresponsive when there is no response obtained after eliciting verbal and painful stimuli.
Watch the following video to know – the AVPU scale
9. Lung sounds
Some abnormal lung sounds that can be heard during respiratory problems include – wheezes, stridor, crackles, rhonchi, and pleural friction rubs.
- Polyphonic wheezes are loud, musical, and continuous. These breath sounds occur in expiration and inspiration and are heard over anterior, posterior, and lateral chest walls.
- Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration, or throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone.
- Stridor sound is a type of wheezing and is heard on inspiration and is a high-pitched whistling or gasping sound with harsh sound quality.
- Coarse crackles are discontinuous, brief, popping lung sounds. Compared to fine crackles they are louder, lower in pitch, and last longer. They have also been described as a bubbling sound.
- Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Fine crackles are also similar to the sound of wood burning in a fireplace, or hook and loop fasteners being pulled apart or cellophane being crumpled.
- Pleural friction rubs are the squeaking or grating sounds of the pleural linings rubbing together and can be described as the sound made by treading on fresh snow.
Watch the following video to know – abnormal lung sounds
10. Neurovascular assessment
There are five Ps essential in conducting neurovascular assessment – pain, pulse, pallor, paresthesia, and paralysis. Start by assessing if there is pain felt within the affected area. Then check for symmetry of pulses especially if it’s weak or thready. Visually inspect for pallor. Determine if there is paresthesia by eliciting stimuli along the affected area. Lastly, check for paralysis by asking the patient to move the affected part.
Watch the following video to know – circulatory checks 5 Ps nursing mnemonics
These are the 10 best nursing mnemonics that come as visual memory aids, abbreviations, and tricks that can help you retain nursing information.
“Nurses are the hospitality of the hospital.” – Carrie Latet