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Nursing · Study reference

Nursing assessment scales, on one page

The bedside scales and criteria you are asked to recall: SIRS, Braden, Morse fall, pressure injury stages, edema grades, the rule of nines and the Parkland formula, the Cushing triad, muscle strength grades, RASS, CIWA-Ar, pain scales and the named positions. Each one as a study card with its items, scoring and bands, and a fictional scenario to practise on. For study only, not for patient care.

  • 14 scales and criteria
  • Scoring and bands on each card
  • Fictional practice scenarios
  • No sign-up needed

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The study cards

Fourteen scales, each on one card

Every card gives the items and their points, how the total reads, and one fictional scenario to practise on. For study only, not for patient care: nothing about a real person is entered or rated here. Jump to a scale:

Sepsis screen and neuro

The SIRS criteria, the Cushing triad, the 0 to 5 muscle strength scale and the basics of the NIH Stroke Scale.

Card 1 · Sepsis screen and neuro

SIRS criteria

Four quick signs that the body is mounting a systemic inflammatory response. Two or more of the four meet the definition of SIRS; in the 1991 consensus definitions, sepsis was SIRS plus a documented or suspected infection.

SignThreshold
TemperatureAbove 38 °C, or below 36 °C
Heart rateAbove 90 beats per minute
BreathingRespiratory rate above 20 per minute, or an arterial CO2 (PaCO2) below 32 mm Hg
White blood cellsAbove 12,000 per µL, or below 4,000 per µL, or more than 10% immature (band) forms

How it reads

SIRS present
2 or more of the 4 criteria
Not SIRS
0 or 1 criterion
  • The criteria come from the 1991 consensus conference of the American College of Chest Physicians and the Society of Critical Care Medicine, published in 1992. They were chosen because each is quickly available at the bedside.
  • SIRS can be caused by things other than infection, such as trauma, burns or pancreatitis. The criteria describe the response, not its cause.
Practice scenario (fictional)

A fictional chart reads: temperature 38.6 °C, heart rate 112, respiratory rate 18, no blood gas drawn, white cells 9,800 per µL with 4% bands. How many SIRS criteria are met?

Card 2 · Sepsis screen and neuro

Cushing triad

Three vital-sign changes that together are a classic late warning of rising pressure inside the skull (intracranial pressure, ICP) and of possible brain herniation. It is a pattern to recognise, not a score.

SignWhat is happening
BradycardiaThe heart rate slows, from heightened vagal tone
HypertensionBlood pressure rises, from systemic vasoconstriction that tries to keep blood flowing to the brain
Irregular breathingThe breathing pattern becomes irregular as the brainstem is affected
  • Alongside the triad, a falling Glasgow Coma Scale and fixed, dilated pupils are the other bedside markers of a rise in ICP. The GCS has its own study card on the nurse report sheet page.
  • The full triad is a late sign. Bradycardia alone can appear with a rise in ICP before the blood pressure or the breathing changes.

The Glasgow Coma Scale card lives on the nurse report sheet page.

Practice scenario (fictional)

A fictional scenario after a head injury: over an hour the heart rate drifts from 88 to 52, the blood pressure climbs from 128/80 to 190/92, and the breathing becomes irregular. Which pattern does this match?

Card 3 · Sepsis screen and neuro

Muscle strength grades (0 to 5)

The manual muscle testing scale, also called the Medical Research Council scale: each muscle group is graded from 0 to 5 by how it moves against gravity and against the examiner’s resistance, and written as a fraction such as 4/5.

GradeNameWhat is seen
0NoneNo muscle contraction
1TraceA flicker or twitch of contraction, but no movement
2PoorActive movement only when gravity is eliminated (for example, sliding sideways on the bed)
3FairActive movement against gravity, but not against resistance
4GoodActive movement against gravity and some resistance
5NormalActive movement against gravity and the examiner’s full resistance
  • The expected finding is 5/5 and equal on both sides. The 0 to 5 words (none, trace, poor, fair, good, normal) are the common textbook labels; the Open RN table lists the grades by their descriptions.
Practice scenario (fictional)

A fictional finding: the person lifts the leg off the bed against gravity, but cannot hold it there when the examiner pushes down lightly. Which grade fits?

Card 4 · Sepsis screen and neuro

NIH Stroke Scale (NIHSS): the basics

The NIH Stroke Scale, the standard bedside measure of stroke severity, scores 11 items for a total of 0 to 42. The higher the total, the more severe the neurological impairment. This card covers the shape of the scale, not the item-by-item scoring.

FeatureDetail
Items11 items, each scored on its own small range, added together
Total0 to 42; 0 means no deficit on the scale, and higher means more impairment
DomainsLevel of consciousness, eye movements, visual fields, facial palsy, motor function of the arms and legs, sensation, limb ataxia, dysarthria (speech clarity), aphasia (language) and extinction or inattention (neglect)
Blind spotsIt is weighted toward cortical function and limb movement, so strokes in the posterior circulation (vertigo, truncal ataxia, cranial nerve and swallowing signs) can score low despite serious deficits
  • Learn the direction of the score first: on this scale a higher number is worse. On the Glasgow Coma Scale, by contrast, a higher number is better.
Practice scenario (fictional)

Which statement about the NIH Stroke Scale is right?

Skin and falls

The Braden Scale, the pressure injury stages, pitting edema grades and the Morse Fall Scale.

Card 5 · Skin and falls

Braden Scale

Predicts the risk of a pressure injury from six subscales. Five are scored 1 to 4 and the last 1 to 3, for a total of 6 to 23. A lower total means higher risk. Developed by Barbara Braden and Nancy Bergstrom in the late 1980s.

RangeSubscaleFrom 1 (worst) to the top score (best)
1 to 4Sensory perception1 completely limited (unresponsive to painful stimuli, or limited ability to feel pain over most of the body) · 2 very limited · 3 slightly limited · 4 no impairment
1 to 4Moisture1 constantly moist · 2 often moist (linen changed at least once a shift) · 3 occasionally moist (an extra change about once a day) · 4 rarely moist
1 to 4Activity1 bedfast · 2 chairfast · 3 walks occasionally, short distances · 4 walks frequently (outside the room at least twice a day)
1 to 4Mobility1 completely immobile · 2 very limited (occasional slight changes) · 3 slightly limited (frequent slight changes) · 4 no limitations
1 to 4Nutrition1 very poor (rarely more than a third of a meal; or NPO or clear liquids or IV for more than 5 days) · 2 probably inadequate · 3 adequate · 4 excellent
1 to 3Friction and shear1 problem (needs moderate to maximum help to move; slides against the sheets) · 2 potential problem · 3 no apparent problem

Risk by total score

Severe (very high) risk
9 or less
High risk
10 to 12
Moderate risk
13 to 14
Mild risk
15 to 18
At-risk status
18 or less, as the AHRQ toolkit summarises it
  • Besides the total, a low score on any single subscale is addressed in the care plan on its own.
Practice scenario (fictional)

A fictional rating: sensory perception 3, moisture 2, activity 1, mobility 2, nutrition 2, friction and shear 1. What is the total, and which band is it in?

Card 6 · Skin and falls

Pressure injury stages

The 2016 staging system describes how deep the tissue damage goes. Since 2016 the term is pressure injury (not ulcer) and the stages use Arabic numerals (Stage 3, not III), because an injury can exist before the skin is open.

StageNameWhat is seen
1Stage 1Intact skin with a localized area of nonblanchable redness (it does not turn white when pressed). Purple or maroon colour is not Stage 1; it may be deep tissue injury.
2Stage 2Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red and moist, and may look like an intact or ruptured blister. Shallow.
3Stage 3Full-thickness skin loss: fat is visible, but fascia, muscle, tendon, ligament, cartilage and bone are not exposed. Slough or eschar, undermining and tunnelling may be present.
4Stage 4Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.
UUnstageableFull-thickness loss whose extent cannot be confirmed because slough or eschar hides the base. Once cleared, it is a Stage 3 or 4.
DTPIDeep tissue pressure injuryPersistent, nonblanchable, deep red, maroon or purple discoloration of intact or non-intact skin, or a dark wound bed or blood-filled blister. It can look different on darkly pigmented skin.
  • The stages describe depth, not a sequence: an injury does not have to pass through Stage 1 and 2 before it is a Stage 3.
  • The 2016 definition adds one exception to unstageable: stable eschar (dry, adherent, intact, without redness or fluctuance) on the heel or an ischemic limb is not softened or removed.
Practice scenario (fictional)

A fictional description of a wound over the sacrum: full-thickness loss with yellow fat visible in the base, a little slough at one edge, and no fascia, muscle, tendon or bone seen. Which stage is it?

Card 7 · Skin and falls

Pitting edema grades (1+ to 4+)

Press the swollen skin over a bone, such as the tibia, and note two things: how deep the pit is, and how long it takes to fill back in. If no pit forms, the edema is nonpitting.

GradeDepth of the pitRebound
1+Up to 2 mm, barely detectableFills back immediately
2+3 to 4 mmFills back in under 15 seconds
3+5 to 6 mmTakes up to 30 seconds to fill back
4+8 mm, a deep pitTakes more than 20 seconds to fill back
  • Textbooks draw the seconds slightly differently (the 3+ and 4+ times overlap in several of them). The depth of the pit is the more consistent marker, and the grade is always a judgement.
Practice scenario (fictional)

A fictional finding: pressing over the tibia leaves a pit about 4 mm deep that fills back in roughly 10 seconds. Which grade fits?

Card 8 · Skin and falls

Morse Fall Scale

Six items that add up to a fall-risk score of 0 to 125 for hospitalised patients, from Janice Morse’s 1989 work. Unlike the Braden Scale, a higher Morse total means higher risk.

PointsItemOptions
0 or 25History of fallingNo 0 · Yes 25 (a fall during this admission, or an immediate history of falls before it)
0 or 15Secondary diagnosisNo 0 · Yes 15 (two or more medical diagnoses in the chart)
0, 15 or 30Ambulatory aidNone, bed rest or walks with a nurse 0 · Crutches, cane or walker 15 · Holds onto furniture 30
0 or 20IV or IV accessNo 0 · Yes 20 (an intermittent-use or continuous intravenous line)
0, 10 or 20GaitNormal, bed rest or wheelchair 0 · Weak 10 · Impaired 20
0 or 15Mental statusKnows own limits 0 · Overestimates or forgets limits 15

Risk by total score

Low risk
0 to 24
Moderate risk
25 to 44
High risk
45 to 125
  • These are the bands reported in the source paper. Some printed forms run moderate as 25 to 45 and high as above 45, so a total of exactly 45 can land either way, and facilities set their own cut-off for extra precautions: learn the one your unit uses.
Practice scenario (fictional)

A fictional rating: fell at home last month (yes), has two diagnoses (yes), walks with a walker, has a saline lock in place, gait is weak, and the person knows their own limits. What is the total and the band?

Burns and fluids

The rule of nines for burn size and the Parkland formula that is built on it.

Card 9 · Burns and fluids

Rule of nines

A quick estimate of how much of the total body surface area (TBSA) a burn covers. Each region of an adult body is worth 9% or a multiple of it; front and back halves are counted separately and added up.

TBSARegion (adult)How it splits
9%Head and neckFront and back together
9% eachEach arm4.5% front + 4.5% back
18%Front of the trunkChest 9% + abdomen 9%
18%Back of the trunkUpper back 9% + lower back 9%
18% eachEach leg9% front + 9% back
1%Perineum (genital area)The last 1% that makes 100
  • For the fluid formulas built on it, such as Parkland, only partial-thickness and full-thickness burns are counted; superficial (first-degree) burns are left out.
  • For small or scattered burns, the person’s own open hand (palm and fingers) is about 1% of their body surface.
  • Children have proportionally larger heads and smaller legs, so a Lund-Browder chart is used for them instead of the adult nines.
Practice scenario (fictional)

A fictional adult has partial-thickness burns over the whole front of the chest and abdomen and the whole of the right arm, front and back. What is the estimate?

Card 10 · Burns and fluids

Parkland formula

The classic estimate of how much IV fluid a person with a large burn needs in the first 24 hours. It is built on the rule of nines, so learn the two together. For study only: this page does no calculation for a real person.

Part of the formulaDetail
The formula4 mL × body weight in kg × % TBSA burned = the volume for the first 24 hours
Which burns countPartial-thickness and full-thickness burns only
The fluidLactated Ringer solution, a balanced crystalloid
The splitHalf of the volume in the first 8 hours, the other half over the next 16 hours
The clockThe 24 hours start at the time of the burn, not at arrival in hospital
When it appliesThe source describes it for partial- and full-thickness burns over 10% TBSA, with the rate then adjusted to the hourly urine output; thresholds differ between burn programs
  • Worked example from the source: 100 kg and a 50% burn gives 4 × 100 × 50 = 20,000 mL, so 10 L in the first 8 hours and 10 L over the next 16.
  • The formula was published by Baxter and Shires in 1968. Burn programs now teach a range of 2 to 4 mL/kg per % burned, which is why the number on an exam depends on the version being taught.
Practice scenario (fictional)

A fictional adult weighs 70 kg and has a 30% TBSA partial-thickness burn. Using 4 mL/kg per %, what is the 24-hour volume, and how much of it is planned for the first 8 hours?

Sedation, withdrawal, pain and positions

The Richmond Agitation-Sedation Scale, the CIWA-Ar items, three pain scales and the named bed positions.

Card 11 · Sedation, withdrawal, pain and positions

Richmond Agitation-Sedation Scale (RASS)

A ten-point scale from +4 (combative) through 0 (alert and calm) to −5 (unarousable). The positive side grades agitation; the negative side grades sedation by how much stimulation it takes to get a response, and for how long.

ScoreTermDescription
+4CombativeOvertly combative or violent; an immediate danger to staff
+3Very agitatedPulls on or removes tubes or catheters, or is aggressive toward staff
+2AgitatedFrequent non-purposeful movement, or fights the ventilator
+1RestlessAnxious or apprehensive, but the movements are not aggressive or vigorous
0Alert and calm
−1DrowsyNot fully alert, but stays awake (more than 10 seconds) with eye contact, to voice
−2Light sedationBriefly (less than 10 seconds) awakens with eye contact, to voice
−3Moderate sedationAny movement, but no eye contact, to voice
−4Deep sedationNo response to voice, but any movement to physical stimulation
−5UnarousableNo response to voice or to physical stimulation
  • The procedure in the original 2002 paper follows the scale’s order: observe first, then speak, and only use physical stimulation when there is no response to voice.
Practice scenario (fictional)

A fictional observation: eyes closed as you approach. When you say the name, the eyes open and meet yours, then close again within a few seconds. Which score fits?

Card 12 · Sedation, withdrawal, pain and positions

CIWA-Ar items

The Clinical Institute Withdrawal Assessment for Alcohol, revised: ten items that rate the severity of alcohol withdrawal. Nine are scored 0 to 7 and one, orientation, 0 to 4, for a total of 0 to 67. Higher means more severe.

RangeItemWhat is rated
0 to 7Nausea and vomitingFrom none to constant nausea with frequent vomiting
0 to 7TremorThe outstretched hands, from none to severe even with the arms not extended
0 to 7Paroxysmal sweatsFrom none to drenching sweats
0 to 7AnxietySubjective distress and nervousness
0 to 7AgitationRestlessness and excessive motor activity
0 to 7Tactile disturbancesItching, pins and needles, burning or numbness, up to hallucinations
0 to 7Auditory disturbancesSounds that are not there, up to continuous hallucinations
0 to 7Visual disturbancesLight sensitivity up to continuous visual hallucinations
0 to 7Headache or fullness in the headFrom none to extremely severe
0 to 4Orientation and clouding of sensoriumOrientation to date and place, and clarity of thinking

How an item reads

No symptoms
0
Mild
1 to 3
Moderate to severe
4 to 7
  • Programs and facilities set the total-score cut-offs they act on, and the published cut-offs differ, so learn the ones in your own course materials rather than a single number from this card.
Practice scenario (fictional)

A fictional scoring: each of the nine 0-to-7 items is rated 2, and orientation is rated 1. What is the total?

Card 13 · Sedation, withdrawal, pain and positions

Pain scales: 0 to 10, FLACC and PAINAD

Three tools that all end on a 0 to 10 line, so they can be compared: the self-report number for people who can say how much it hurts, and two observational scales for people who cannot.

TotalScaleHow it works
0 to 10Numeric ratingThe person rates their own pain: 0 is no pain and 10 is the worst pain imaginable. A screen; a fuller assessment (PQRSTU or OLDCARTS) follows
0 to 10FLACCFace, Legs, Activity, Cry, Consolability: each observed and scored 0, 1 or 2. For ages 2 months to 7 years, or anyone who cannot report pain in words
0 to 10PAINADBreathing, negative vocalisation, facial expression, body language, consolability: each 0 to 2. For people with advanced dementia who cannot say how they feel
  • FLACC row by row: Face 0 no expression or a smile, 1 occasional grimace or frown, 2 frequent quivering chin or clenched jaw · Legs 0 relaxed, 1 uneasy or tense, 2 kicking or drawn up · Activity 0 lying quietly, 1 squirming or shifting, 2 arched, rigid or jerking · Cry 0 none, 1 moans or whimpers, 2 crying steadily or screaming · Consolability 0 content, 1 reassured by touch or talking, 2 difficult to console.
  • When the words and the number do not match (for example “tolerable” but a 7 out of 10), the answers are validated with follow-up questions rather than re-rated by the observer.
Practice scenario (fictional)

A fictional observation of a three-year-old after surgery: an occasional grimace, restless legs, squirming, moaning now and then, and settles when held. What is the FLACC total?

Card 14 · Sedation, withdrawal, pain and positions

Named positions, Fowler’s to Trendelenburg

The bed and body positions named in orders and in report, with the head-of-bed angles that define the Fowler’s family.

PositionWhat it is
SupineFlat on the back
ProneOn the stomach, head turned to one side
LateralOn one side, the top leg flexed over the bottom leg (relieves pressure on the coccyx)
Sims’Halfway between the supine and prone positions, legs flexed, a pillow under the top leg; used for some procedures such as an enema
Semi-Fowler’sHead of the bed at 30 to 45 degrees; better tolerated for long periods than full Fowler’s
Fowler’sHead of the bed at 45 to 90 degrees, hips slightly flexed; promotes lung expansion
High Fowler’sHead of the bed at 90 degrees, sitting upright
TrendelenburgThe head of the bed lower than the feet
TripodSitting and leaning forward with the elbows on the knees or a table; the posture people short of breath take on their own
Practice scenario (fictional)

A fictional order asks for the head of the bed at about 35 degrees. Which named position is that?

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Sources

Where these facts come from

Every card is written in our own words from these public sources. Scales are revised and facilities set their own cut-offs, so check anything important against your program’s materials.

Questions

Common questions

Four signs from the 1991 consensus definitions: a temperature above 38 °C or below 36 °C; a heart rate above 90; a respiratory rate above 20 or a PaCO2 below 32 mm Hg; and a white cell count above 12,000 or below 4,000 per µL, or more than 10% band forms. Two or more of the four meet the definition of SIRS. The card at the top of the page has the table and a scenario.

Six subscales: sensory perception, moisture, activity, mobility and nutrition are each scored 1 to 4, and friction and shear 1 to 3, for a total of 6 to 23. Lower means higher risk: 9 or less is severe risk, 10 to 12 high, 13 to 14 moderate and 15 to 18 mild, and the AHRQ toolkit summarises 18 or less as at-risk status.

Six items add up to 0 to 125: history of falling (25), secondary diagnosis (15), ambulatory aid (15 for crutches, cane or walker; 30 for holding furniture), an IV or IV access (20), gait (10 weak, 20 impaired) and mental status (15 for overestimating or forgetting limits). In the bands many hospitals use, 0 to 24 is low risk, 25 to 44 moderate and 45 or more high; some forms print moderate as 25 to 45, and units set their own cut-off.

Press over a bone and note the depth of the pit and how long it takes to fill back in. In the Open RN grading, 1+ is up to 2 mm and rebounds immediately, 2+ is 3 to 4 mm and rebounds in under 15 seconds, 3+ is 5 to 6 mm and takes up to 30 seconds, and 4+ is an 8 mm pit that takes more than 20 seconds. Textbooks draw the seconds slightly differently; the depth is the steadier marker.

On the nurse report sheet page, which has the full card with the current structured-approach descriptors, how a rating is written and reported, and practice scenarios. This page links to it rather than repeating it.

No. Everything here is for study. The cards explain what each scale measures and how it is scored, and the scenarios are fictional, written to fit the published criteria. Nothing about a real person is typed in or rated on this page, and with a patient your facility’s policy, its forms and your instructor come first.

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