Systematic Clinical Assessment – GCC Nursing Guide

Core Principle The ABCDE approach is a systematic, prioritised method used across all clinical settings. Assess and treat each finding before progressing to the next element. Reassess continuously after every intervention.

Airway

Status

Patent — no intervention needed
At risk — potential compromise (altered GCS, blood/secretions)
Obstructed — immediate intervention required

Abnormal Sounds

Sound	Cause
Stridor	Upper airway obstruction (high-pitched inspiratory)
Stertor	Partial soft-tissue obstruction (snoring quality)
Gurgling	Pooled secretions / fluid

Interventions (escalating)

Head-tilt chin-lift (not if C-spine injury) / Jaw thrust
Suction under direct vision
Airway adjuncts: OPA (Guedel) / NPA
Definitive airway: LMA / Endotracheal tube (ETT)

Breathing

Assessment Parameters

RR 12–20/min — most sensitive early indicator of deterioration
Depth, pattern, accessory muscle use
SpO₂ (target ≥95%; 88–92% in COPD)
Trachea position (midline vs deviated)
Chest expansion symmetry

Percussion Notes

Resonant — normal air-filled lung
Dull — consolidation, pleural effusion, collapse
Hyperresonant — pneumothorax, emphysema

Breath Sounds

Crackles (fine/coarse) — pulmonary oedema, fibrosis, pneumonia
Wheeze — bronchoconstriction (asthma/COPD)
Bronchial breathing — consolidation
Reduced/absent — pleural effusion, pneumothorax

Circulation

Heart rate & rhythm (radial pulse — rate, rhythm, character)
Blood pressure — bilateral if vascular concern
Capillary refill time: <2 s = normal; >2 s = impaired perfusion
Skin: temperature (warm/cool/cold), colour (pale/mottled/cyanosed)
Urine output minimum: 0.5 mL/kg/hour
Peripheral IV access, fluid balance review
12-lead ECG if arrhythmia suspected

Disability (Neuro)

AVPU: Alert / Voice / Pain / Unresponsive
GCS: Eyes (1–4) + Verbal (1–5) + Motor (1–6) = 3–15
Pupils: PERLA — size, equality, reactivity; note fixed/dilated
Blood glucose: ALWAYS check in any patient scoring V, P, or U on AVPU. Normal 4–7 mmol/L fasting
Limb movement: equality, power, tone
Signs of raised ICP: Cushing's triad (bradycardia, hypertension, irregular breathing)

Exposure

Temperature (core — tympanic, oral, rectal; peripheral)
Full head-to-toe skin inspection — rashes, wounds, bruising, pressure injuries
Relevant history: allergies, medications, past medical history
SBAR handover to escalate findings
Maintain dignity — expose only what is necessary; cover promptly
Note: MIST in trauma (Mechanism / Injuries / Symptoms / Treatment)

ABCDE: Key Principles for GCC Practice

Sequence Rules

Treat any life-threatening finding before advancing to the next letter
Call for help early — do not delay escalation
Reassess after every intervention
Document with timestamp at each step

Common Pitfalls

Missing an obstructed airway due to noise distraction
Overlooking abnormal RR as the earliest deterioration sign
Not checking blood glucose in altered consciousness
Skipping exposure due to privacy concerns — balance with clinical need

Normal Adult Vital Signs Reference

Parameter	Normal Range	Clinical Note
Heart Rate	60–100 /min	Radial pulse; note rhythm and character
Respiratory Rate	12–20 /min	Most sensitive early indicator of deterioration
SpO₂	≥95%	88–92% target in known hypercapnic COPD patients
Systolic BP	90–140 mmHg	Bilateral comparison if vascular concern
Temperature	36.0–37.9 °C	Pyrexia ≥38.0°C; hypothermia <36.0°C
GCS	15/15	Eyes 4 + Verbal 5 + Motor 6
AVPU	Alert	Any score below Alert warrants urgent review
Urine Output	≥0.5 mL/kg/hr	Oliguria <0.5 mL/kg/hr requires escalation
Blood Glucose	4.0–7.0 mmol/L	Fasting; random may be up to 11.1 mmol/L in non-diabetics

NEWS2 — National Early Warning Score 2

Purpose NEWS2 provides a standardised scoring system to identify deteriorating patients and prompt appropriate escalation. Aggregate score triggers graded clinical response.

Parameter	Score 3	Score 2	Score 1	Score 0	Score 1	Score 2	Score 3
RR (/min)	≤8	—	9–11	12–20	—	21–24	≥25
SpO₂ Scale 1 (%)	≤91	92–93	94–95	≥96	—	—	—
SpO₂ Scale 2 (%)*	≤83	84–85	86–87	88–92	93–94 on O₂	95–96 on O₂	≥97 on O₂
On O₂	—	Yes (+2)	—	No (0)	—	—	—
Systolic BP (mmHg)	≤90	91–100	101–110	111–219	—	—	≥220
HR (/min)	≤40	—	41–50	51–90	91–110	111–130	≥131
Temperature (°C)	≤35.0	—	35.1–36.0	36.1–38.0	38.1–39.0	≥39.1	—
Consciousness	—	—	—	Alert	—	—	New confusion / V / P / U (+3)

*Scale 2 is used for patients with known hypercapnic respiratory failure (e.g., COPD) or COVID-19 where 88–92% SpO₂ is the target range.

NEWS2 Clinical Response Thresholds

Score	Risk Level	Monitoring Frequency	Response Required
0–4	LOW	Minimum 12-hourly	Routine ward nursing care; nurse-initiated response
3 (single parameter)	LOW-MEDIUM	Minimum 1-hourly	Urgent review by ward nurse/doctor within 1 hour
5–6	MEDIUM	Minimum 1-hourly	Urgent review by ward doctor within 1 hour; consider ICU referral
≥7	HIGH	Continuous monitoring	Emergency assessment within 30 minutes; critical care team involvement

Postural (Orthostatic) Hypotension

Measure BP supine/lying first — allow 5 minutes rest
Patient stands — re-measure at 1 minute and 3 minutes
Positive result: systolic drop of >20 mmHg (or diastolic >10 mmHg) within 3 minutes of standing
Associated symptoms: dizziness, presyncope, falls risk
GCC context: common in hot climate dehydration, Ramadan fasting periods, elderly patients

Arterial BP Measurement Technique

Cuff Selection

Bladder width should be 40% of arm circumference
Bladder length should encircle 75–80% of arm
Too small a cuff → falsely high reading
Too large a cuff → falsely low reading

Technique Points

Patient seated, arm at heart level, 5 minutes rest
Auscultatory: Korotkoff phase I (systolic) to phase V (diastolic)
Oscillometric (automated): validated machines preferred in GCC hospitals
Repeat if abnormal; average two readings 1–2 min apart
Document arm used; note arrhythmia if present

Neurological / Head Assessment

Cranial Nerve Quick Screen (CN I–XII)

CN	Name	Test
I	Olfactory	Smell identification (each nostril)
II	Optic	Visual acuity, fields, fundoscopy
III/IV/VI	Oculomotor/Trochlear/Abducens	EOM, pupil response, ptosis
V	Trigeminal	Facial sensation, corneal reflex, mastication
VII	Facial	Facial expression symmetry, taste
VIII	Vestibulocochlear	Hearing, Rinne/Weber
IX/X	Glossopharyngeal/Vagus	Gag reflex, uvula midline, voice
XI	Accessory	Shoulder shrug, neck rotation against resistance
XII	Hypoglossal	Tongue protrusion, fasciculations

Cerebellar Signs

Finger-nose test (intention tremor, past-pointing)
Heel-shin test (lower limb coordination)
Rapid alternating movements (dysdiadochokinesia)
Romberg test: feet together, arms out, eyes closed — positive if sways/falls (sensory ataxia)

Gait Assessment

Ataxic — broad-based, cerebellar
Spastic/Scissor — upper motor neuron (stroke/MS)
Steppage — foot drop (common peroneal nerve)
Antalgic — pain-avoidance, limping
Parkinsonian — shuffling, festinant, reduced arm swing

Eye Examination

Visual Acuity: Snellen chart at 6 metres; record 6/6 (normal), 6/12, 6/60 etc.
Visual Fields: Confrontation testing — compare patient to examiner's fields in all quadrants
Fundoscopy: Papilloedema (raised ICP — blurred disc margins), diabetic retinopathy (microaneurysms/exudates/neovascularisation), hypertensive retinopathy (AV nipping, flame haemorrhages)
Pupils: PERLA — size (2–5 mm normal), equality, direct and consensual light reflex, accommodation

Neck Examination

Lymph Node Regions

Anterior cervical chain (along sternomastoid)
Posterior cervical chain
Submental / submandibular
Supraclavicular (Virchow's node — left: gastric/thoracic malignancy)
Axillary (anterior/posterior/central groups)

Document: size, consistency, tenderness, mobility, overlying skin changes

Thyroid Assessment

Inspection: midline swelling moves on swallowing
Palpation: from behind — size, symmetry, consistency, nodules
Auscultation: thyroid bruit (hyperthyroidism/hypervascular)
Pemberton's sign: arms raised for goitre causing SVC obstruction

JVP Assessment

Patient at 45°; normal <4 cm above sternal angle
Hepatojugular reflux: pressure on RUQ causes JVP rise (>4 cm sustained = positive)
Elevated JVP: right heart failure, tamponade, SVC obstruction

Abdominal Examination

Sequence: Inspect → Auscultate → Percuss → Palpate

Inspection

Distension (fat/fluid/flatus/faeces/fetus)
Scars (midline, Kocher's, Pfannenstiel)
Stoma sites, visible peristalsis
Caput medusae (portal hypertension)
Cullen's sign (periumbilical bruising) / Grey-Turner's sign (flank bruising) — haemorrhagic pancreatitis

Auscultation

Normal bowel sounds: 5–30 clicks/min
Absent (>2 min silence): ileus
Hyperactive/tinkling: early obstruction, diarrhoea
Bruits: renal artery stenosis, aortic aneurysm

Percussion

Liver dullness: right 5th–10th intercostal space midclavicular line
Splenic dullness: left 9th–11th intercostal space lateral
Ascites — shifting dullness: percuss to flank dullness, patient rolls, dullness shifts
Fluid thrill: tap one flank, feel impulse on other (massive ascites)

Palpation

Light palpation first (9 regions): tenderness, guarding
Deep palpation: organomegaly, masses
Guarding: voluntary (pain) vs rigid (peritonism)
Rebound tenderness: Blumberg's sign — peritoneal irritation
Murphy's sign: acute cholecystitis (RUQ inspiration arrest)
McBurney's point tenderness: appendicitis

Extremities Assessment

Peripheral Pulses (0–3+ scale)

0 = absent; 1+ = diminished; 2+ = normal; 3+ = bounding
Radial (wrist), Brachial (antecubital), Femoral (groin)
Popliteal (behind knee), Posterior tibial (medial malleolus)
Dorsalis pedis (dorsum of foot)

Oedema Grading (Pitting)

1+ : 2 mm indent, rapid rebound
2+ : 4 mm indent, rebounds in <15 sec
3+ : 6 mm indent, rebounds in <60 sec
4+ : >8 mm deep, no rebound; may be non-pitting (lymphoedema/myxoedema)

Nail Signs

Clubbing: Schamroth's sign — loss of diamond window between opposed nails; causes: cyanotic heart disease, lung CA, IBD, cirrhosis
Cyanosis: Central (lips/tongue — PaO₂ <85%) vs Peripheral (digits — poor circulation)
Koilonychia: Spoon-shaped nails — iron deficiency anaemia
Leukonychia: White nails — hypoalbuminaemia
Splinter haemorrhages: Infective endocarditis, vasculitis

SOCRATES Pain Assessment

Site

Where is the pain? Can you point to it? Is it localised or diffuse?

Onset

When did it start? Sudden vs gradual? Activity at onset?

Character

Sharp / burning / dull / crushing / cramping / stabbing?

Radiation

Does it spread anywhere? Arm/jaw (cardiac), shoulder (diaphragmatic), groin (renal colic)?

Associations

Nausea, vomiting, sweating, dyspnoea, fever?

Timing

Continuous / intermittent / colicky? Duration? Pattern?

Exacerbating/Relieving

What makes it better or worse? Movement, food, position, rest, medication?

Severity

Score 0–10 (0 = no pain, 10 = worst imaginable). Impact on function/sleep?

Pain Rating Scales

Scale	Population	Description
NRS (Numerical Rating Scale)	Adults, verbal, cognitively intact	0–10 numeric scale; most widely used in GCC hospitals
VAS (Visual Analogue Scale)	Adults, research settings	100 mm line: no pain to worst pain; patient marks position
Verbal Descriptor Scale	Elderly, cross-cultural	None / Mild / Moderate / Severe / Unbearable — useful when numeric concept is unclear
FACES (Wong-Baker)	Children ≥3 years, limited language	6 facial expressions scored 0–10
FLACC	Infants, non-verbal children (0–7 yrs)	Face/Legs/Activity/Cry/Consolability — each 0–2, total 0–10
CPOT	Intubated/unconscious adults (ICU)	Facial expression/body movements/muscle tension/ventilator compliance — each 0–2, total 0–8; score ≥3 = clinically significant pain
Abbey Pain Scale	Dementia patients	Vocalisation/facial expression/body language/behaviour change/physiological indicators — each 0–3; 0–2 no pain, 3–7 mild, 8–13 moderate, 14+ severe

GCC Cultural Considerations Gulf national male patients may present stoically and underreport pain. Female patients may be more expressive. Religious beliefs (e.g., pain as spiritual test) may influence pain reporting. Always use objective tools (CPOT/FLACC) alongside self-report. Arabic-validated versions of NRS and VDS are available.

Handover Communication Tools

SBAR

S – Situation: patient ID, what is happening now
B – Background: diagnosis, history, current treatment
A – Assessment: clinical impression, vital signs, NEWS2
R – Recommendation: what you need / what should happen

ISBAR (extended)

I – Identify: caller name, role, ward; patient name/MRN
Then S, B, A, R as above

ISOBAR

Identify / Situation / Observations / Background / Assessment / Recommendations
Includes vital signs and NEWS2 score explicitly in 'Observations'

SOAP Note Format

S – Subjective: Patient's own words, complaint, pain score, Hx
O – Objective: Vital signs, physical examination findings, NEWS2, investigations
A – Assessment: Clinical impression/working diagnosis, problem list
P – Plan: Investigations ordered, interventions, medications, review time, escalation threshold

DNAR / Advance Directives During comprehensive assessment, verify and document DNAR/advance care plan status. In GCC hospitals: document must be signed by patient/family and senior physician. Escalate to senior nurse/physician if status unclear before any acute event.

Dehydration Assessment

Sign	Significance
Sunken eyes	Moderate–severe dehydration
Dry mucous membranes	Early indicator
Skin turgor (pinch test)	Returns >2 s = poor turgor; unreliable in elderly (skin laxity)
CRT >2 s	Poor peripheral perfusion
Urine colour	Pale straw (hydrated) → dark amber → oliguria <0.5 mL/kg/hr = significant
Postural hypotension	Suggests intravascular depletion ≥1 L in adults

GCC Context High ambient temperatures (up to 50°C summer) and Ramadan fasting significantly increase dehydration risk. Assess carefully in outdoor workers, elderly patients, and patients with diabetes insipidus.

Nutritional Screening — MUST

Malnutrition Universal Screening Tool

Step	Criteria	Score
1 — BMI	>20 = 0 · 18.5–20 = 1 · <18.5 = 2	0–2
2 — Weight loss (3 months)	<5% = 0 · 5–10% = 1 · >10% = 2	0–2
3 — Acute illness effect	Acutely ill & no nutritional intake ≥5 days = +2	0 or 2
Total Score		0–6+

Low risk — routine care, rescreen weekly (hospital) / monthly (care home)

Medium risk — observe; document 3-day dietary intake; dietitian referral if no improvement

High risk — treat; refer to dietitian; nutritional support plan; document

Pressure Injury Risk — Waterlow / Braden

Braden Scale Parameters (each scored 1–3 or 1–4)

Sensory perception: 1 (completely limited) – 4 (no impairment)
Moisture: 1 (constantly moist) – 4 (rarely moist)
Activity: 1 (bedfast) – 4 (walks frequently)
Mobility: 1 (completely immobile) – 4 (no limitations)
Nutrition: 1 (very poor) – 4 (excellent)
Friction & shear: 1 (problem) – 3 (no apparent problem)

Score interpretation: ≤9 Very high risk · 10–12 High risk · 13–14 Moderate · 15–18 At risk · ≥19 No risk

GCC hospitals: reassess every 24–48h or after position change / deterioration. Document repositioning 2-hourly.

Falls Risk — Morse Falls Scale

Item	Score
History of falling (past 3 months)	No=0 / Yes=25
Secondary diagnosis	No=0 / Yes=15
Ambulatory aid	None/bedrest/nurse assist=0 · Crutches/cane/walker=15 · Furniture=30
IV/heparin lock	No=0 / Yes=20
Gait/transferring	Normal/bedrest=0 · Weak=10 · Impaired=20
Mental status	Oriented to own ability=0 · Overestimates/forgets limits=15

Thresholds: 0–24 Low · 25–44 Medium · ≥45 High risk → implement falls prevention protocol

Mental Health Screening Tools

Tool	Screens For	Threshold
PHQ-9	Depression (9 questions, 0–27)	0–4 none, 5–9 mild, 10–14 moderate, 15–19 mod-severe, 20+ severe
GAD-7	Generalised Anxiety (7 items, 0–21)	5 mild, 10 moderate, 15 severe
AUDIT	Alcohol use disorders (10 questions)	Score ≥8 = hazardous drinking; ≥16 = harmful; ≥20 = dependence likely
CAGE	Alcohol dependency screening	2+ positive answers = clinically significant (Cut down / Annoyed / Guilty / Eye-opener)

Cognitive Screening

AMTS — Abbreviated Mental Test Score (10 questions)

Age / Date of birth / Year / Time (to nearest hour)
Name of place / Recognition of 2 persons / Year of World War I/II end
Name of current monarch / Count 20–1 backwards / Address recall (given at start)
Score <7/10 = cognitive impairment; refer for further assessment

4AT — Rapid Delirium Assessment

Alertness (0–4) + AMT4 (0–2) + Attention (0–2) + Acute change (0–4)
Score ≥4 = possible delirium · 1–3 = possible cognitive impairment · 0 = delirium unlikely
Validated tool for bedside delirium screening; Arabic version available

GCC Multi-Language Assessment Arabic-validated versions of PHQ-9, GAD-7, AMTS, 4AT, and NRS are available and recommended for use with Arabic-speaking patients. Document language used during assessment.