Nursing Assessments

December 9, 2015

As a nurse, there are a nursing assessments that we can use to help us provide good care to our patients. This blog is a list of assessment tools that have been suggested by people on the group on Facebook on the 9th of December 2015. Here are the 19 Assessments that were suggested.




‘MUST’ is an acronym for Malnutrition Universal Screening Tool. It has been developed by BAPEN for identifying those at risk of malnutrition or Obesity.

The assessment uses the BMI (body mass index) chart, a weight loss score and a acute disease effect score. It also contains alternative measurement instructions and tables estimating the height of a person from the ulna length and the BMI category of a person from the mid upper arm circumference.

To download the assessment and for more information click on the link below.

2. The Waterlow Score 

The Waterlow score, created by Judy Waterlow, is a commonly used risk assessment and prevention tool for pressure sore.  Its really simplistic and easy to use. For more information and to download a copy of the assessment tool please visit Judy Waterlows website by following the link below.

3. HoNOS

The HoNOS (Health of the Nation outcome scales) was created to measure the health and social functioning of people with severe mental illness. It consists of 12 items which measure behaviour, impairment, symptoms and social functioning. For more information click the link below.


‘LENSES’,  an acronym for liverpool university neuroleptic side effect rating scale, is a tool used to measure the side effects of antipsychotic medications. It consists of 51 questions in total which 10 are ‘red herrings’ designed with the purpose to test the robustness of the results.

5. Glasgow depression scale

The Glasgow depression has been developed for individuals with a learning disability to indicate depression and anxiety. Click the link below to view the scale. A score of over 13 indicates depressions with a score of 15 above indicating anxiety.

8. DLD

“DLD’ is an Acronym for Dementia Learning Disability. Its a questionnaire for carers to asses cognitive function as a result of dementia. The questionnaire is available to purchase by follow the link below.

9. ABS 3

‘ABS 3’ is an acronym for the third addition for the adaptive behaviour assessment system. Not only does it assess for adaptive behaviour, it also has other uses which can be found by following the link below.

10. PPP 

‘PPP’ is an acronym for Paediatric Pain Profile. It is a behaviour rating scale for assessing pain in children with severe physical and learning impairments. For more information click on the link below.

11. Outcome Stars

Outcomes star or Spectrum Star is an assessment designed for adults to enable them to manage there autism and make choices for them. Outcome star have a lot of information about the assessment on there website. To visit please click on the link below.


Grist is an acronym for Galatean Risk and Safety Tool. Its developer states its a web-based decision support for mental-health risk, safety, and wellbeing. For more information on GRiST and it concept, visit the website by clicking the link below.


DSQIID is an acronym for Dementia Screening Questionnaire for Individuals with Intellectual disabilities. Created by Professor Shoumitro Deb, it can be downloaded from the University of Birmingham website by following the link below.

14. Vinelands-II

The Vinelands-II is the Vineland Adaptive Behaviour Scale (second addition). The aim of the scales is to measure adaptive behaviour from birth to adulthood. for more information and to purchase, please click on the link below which will direct you to

15 . MEWS

MEWS is an acronym for modified early warning systems. Is a simple system where the nurse takes and records a persons vital signs and if they fall into a red zone on the chart, then the nurse is prompted to take a MEWS score. For more information please click on the link below.

16. BBAT 

BBAT is a acronym brief behavioural analysis tool. Its a informant based assessment tool to use in functional analysis. For more information and a handy powerpoint presentation, click on the link below.

17. Abbey Pain Scale

The Abbey pain scale has been developed for those with dementia who cannot verbalise. It scores from 0 to 3 and consists of 6 questions. To download the assessment click on the link below.

18 – START

START is an acronym Short-Term assessment of Risk and Treatablity. It gives the clinician an integrated, balanced opinion to evaluate the patients risk across seven domains: violence to others, suicide, self-harm, self-neglect, unauthorized absence, substance use, risk of being victimized. for more information click on the link below.

19 – MOAS

MOAS is an acronym for Modified Overt Aggression Scale. The assessment asks the person completing it to rate the patients aggressive behaviour over the past week. It has been developed to asses four types of aggressive behaviour: verbal aggression, aggression against property, auto aggression and physical aggression. Higher score indicate more aggression. Click on the link the below for more information.

20 – GCS

‘GCS’ is an acronym for Glasgow Coma Scale. The Glasgow Coma Scale provides a practical method for the assessment of a persons level of consciousness in responses to defined stimuli. Click on the link below for more information.

Please reload


RSVP or Business as usual?

June 6, 2019

Please reload


Please reload

Positive Commitment to Learning Disability Nursing

2016 - copyright of

Design - Sean Ledington