Clinical assessment scores worksheet with answers

Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury opens the eyes spontaneously, talks in sentences but is confused and shows as the best motor response: moves a hand to the site of pressure (localises). Find the Glasgow Coma Scale total GCS = E + V + M.

Practice exercise (made-up values, not clinical guidance). A patient’s blood pressure is 169/88 mmHg. Find the pulse pressure PP.

Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: slightly limited; moisture: rarely moist; activity: chairfast; mobility: slightly limited; nutrition: very poor; friction and shear: no apparent problem. Find the Braden total B.

Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 147/min and a blood pressure of 152/99 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.

Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 107 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?

Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: no; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.

1. 1low risk
2. 2moderate risk
3. 3high risk