Sammie Nursing Assessment Tools
por Hannah Lawless
1. ABCDE (Resuscitation Council, 2015) Airway, Breathing, Circulation, Disability, Exposure
2. AVPU (NICE, 2007) Alert, Vocal, Pain, Unreponsive
3. BMI (WHO, 2004) Body Mass Index
3.1. Healthy weight
4. BM's
4.1. NORMAL RANGE
4.1.1. 4.0 to 6.0 mmol/L (Diabetes UK,
5. MANCHEWS (2015)
5.1. NORMAL RANGES
5.1.1. Resp Rate - 20 to 29
5.1.1.1. Breaths per minutes
5.1.2. HR - 70 to 119
5.1.2.1. Beat per minute (BPM)
5.1.3. BP - 90 to 129
5.1.3.1. Millimeters of Mercury (mm/Hg)
5.1.4. Cap Refill - 1 or 2s
5.1.4.1. Seconds
5.1.5. Temp - 36.5 to 37.5
5.1.5.1. Celcius
5.1.6. O2 - 95% or higher
5.1.6.1. Oxygen satuation
6. Hourly Roundings (SRFT, 2016)
6.1. 4 P's
6.1.1. Pain
6.1.2. Position
6.1.3. Possessions
6.1.4. Personal hygiene
7. MRSA Assessment Methicillin-Resistant Staphylococcus Aureus
8. Hello, my name is... (Granger, 2013)
9. Look, Listen, Measure, Feel
10. STAMP (CMU Hospitals, 2010) Screening Tool for the Assessment of Malnutrition of Peadatrics
10.1. 5 Steps
10.1.1. Diagnosis
10.1.2. Nutritional intake
10.1.3. Weight and height
10.1.4. Overall risk of malnutrition
10.1.5. Care Plan