Clinical Tools

No. Two Nurse's clinical tools (GCS, NEWS2, PediCalc, etc.) process data locally in your browser and never send or save it to a server. Do not enter patient-identifying data: use only the numeric clinical values needed for the calculation. This applies to all currently available calculators.

The GCS assesses level of consciousness by summing three parameters: eye opening (1–4), verbal response (1–5), and motor response (1–6). The total score ranges from 3 (deep coma) to 15 (fully alert and oriented patient). On Two Nurse the calculation is automatic.

The National Early Warning Score 2 recognizes clinical deterioration early based on vital signs: respiratory rate, oxygen saturation, blood pressure, heart rate, temperature, and level of consciousness. The higher the score, the greater the risk: it guides monitoring frequency and care escalation.

The SOFA (Sequential Organ Failure Assessment) quantifies organ dysfunction across 6 systems: respiratory (PaO₂/FiO₂), coagulation (platelets), liver (bilirubin), cardiovascular (MAP/vasopressors), nervous system (GCS), and renal (creatinine/urine output). Each system scores 0–4, for a total of 0–24: the higher the score, the higher the mortality.

The Shock Index is the ratio of heart rate to systolic blood pressure (HR/SBP). It's a rapid indicator of hemodynamic stability: it unmasks occult shock, because tachycardia with borderline blood pressure raises the index even when the individual parameters look normal.

The Apgar Score is a rapid newborn assessment tool devised by Virginia Apgar in 1952. It assigns a score of 0–2 to five physiological parameters — Appearance (color), Pulse (heart rate), Grimace (reflex response), Activity (muscle tone), and Respiration (breathing) — for a total of 0–10. It is recorded at 1, 5, and 10 minutes after birth.

The Silverman-Andersen score is a tool for assessing neonatal respiratory distress, devised by William Silverman and Dorothy Andersen in 1956. It assigns a score of 0–2 to five clinical signs — chest-abdominal movement, intercostal retraction, xiphoid retraction, nasal flaring, and expiratory grunting — for a total of 0–10.

The HEART Score is a risk-stratification tool for emergency department patients with chest pain, developed by Six, Backus, and Kelder (2008). It evaluates five parameters — History, ECG, Age, Risk factors, and Troponin — each scored 0–2, for a total of 0–10. It estimates the risk of major adverse cardiac events (MACE) at 6 weeks.

The ABCD2 Score estimates short-term stroke risk (at 2, 7, and 90 days) after a transient ischemic attack (TIA), developed by Johnston et al. (2007). It evaluates five parameters — Age, Blood pressure, Clinical features, Duration of symptoms, Diabetes — for a total of 0–7.

No, they are two distinct tools with different criteria and weights, both developed by Philip Wells. The Wells Score for DVT (1997/2003) evaluates 9 clinical criteria worth 1 point each plus one negative criterion (alternative diagnosis, -2), for a total of -2 to 9. The Wells Score for pulmonary embolism (2000) evaluates 7 criteria with different weights (1 to 3 points), for a total of 0–12.5. They are not interchangeable.

BMI (Body Mass Index) is calculated by dividing weight in kg by height in meters squared: BMI = kg / m². Per the WHO classification: < 18.5 underweight, 18.5–24.9 normal weight, 25–29.9 overweight, 30–34.9 class I obesity, 35–39.9 class II, ≥ 40 class III.

The Cincinnati Prehospital Stroke Scale (CPSS) evaluates 3 signs: facial asymmetry, arm drift, and speech abnormality. It's used in prehospital emergency care for rapid stroke recognition. 1 out of 3 positive findings corresponds to a 72% probability of an ongoing stroke and calls for activating the stroke code.

MUST (Malnutrition Universal Screening Tool) calculates malnutrition risk by summing 3 scores: current BMI (0–2 points), unplanned weight loss over the last 3–6 months (0–2 points), and the effect of acute disease with no nutritional intake for more than 5 days (0 or 2 points). Score 0 = low risk, 1 = medium, ≥ 2 = high.

REMS (Rapid Emergency Medicine Score) is a prognostic score for estimating in-hospital mortality in non-surgical ED patients. It evaluates 6 parameters: age, heart rate, mean arterial pressure (MAP), respiratory rate, SpO₂, and GCS. Score ≤ 2 = very low risk (mortality < 1%); 3–6 = low; 7–11 = moderate; ≥ 12 = high (> 20%).

The Braden Scale is the most validated tool for assessing pressure injury risk. Developed in 1987 by Braden and Bergstrom, it evaluates 6 subscales — sensory perception, moisture, activity, mobility, nutrition, and friction and shear — with a score of 6–23. The lower the score, the higher the risk. It is particularly indicated in intensive care, surgery, and long-term care.

The Norton Scale is a nursing tool for assessing pressure injury risk (formerly ‘bedsores’). Developed in 1962 by Doreen Norton, it evaluates 5 parameters — physical condition, mental state, activity, mobility, and incontinence — each scored 1–4, for a total of 5–20. Unlike Braden, a lower score indicates higher risk.

The NIHSS (National Institutes of Health Stroke Scale) is the standardized neurological scale for quantifying deficit severity in acute ischemic stroke. It evaluates 15 items — consciousness, gaze, vision, facial palsy, limb strength, ataxia, sensation, language, dysarthria, and neglect — with a score from 0 (no deficit) to 42 (maximal deficit). It's used in the ED, neurology, and advanced prehospital care to guide reperfusion therapy.

The modified Rankin Scale (mRS) is the most widely used tool internationally for measuring the degree of disability or functional dependence in patients after a stroke. It assigns the patient to one of seven grades, from 0 (no symptoms) to 6 (death), based on overall functional level, regardless of the cause of the deficit. It's the primary functional endpoint in most stroke clinical trials, typically assessed at 90 days.

The Conley Scale is a rapid screening tool for identifying hospitalized patients at risk of falling. Developed by Conley, Schultz, and Selvin in 1999, it evaluates 6 items: 3 from history (previous falls, dizziness, incontinence on the way to the bathroom) and 3 from observation (gait impairment, agitation, impaired judgment). The score ranges from 0 to 10; the patient is considered at risk with a score ≥ 2 (cutoff).

The 4AT is a rapid screening tool for delirium and cognitive impairment, developed by MacLullich and colleagues. It evaluates 4 items: alertness, AMT4 (age, date of birth, place, current year), attention (months of the year backward from December), and acute change or fluctuating course. The score ranges from 0 to 12; a score ≥ 4 suggests possible delirium. It's among the most widely used delirium screening tests because it requires no certified training and takes only a few minutes.

SLUMS (Saint Louis University Mental Status Exam) is an 11-item, 30-point cognitive decline screening test, developed by Tariq and colleagues in 2006 with the St. Louis VA Medical Center. It assesses orientation, immediate and delayed memory, calculation, verbal fluency, attention, executive function (clock drawing), and visuospatial function. It is distributed free of charge by Saint Louis University and requires no usage license.

The Tinetti Scale, or POMA (Performance Oriented Mobility Assessment), is a direct-observation tool developed by Mary Tinetti in 1986 to assess balance and gait in the elderly and estimate fall risk. It consists of two subscales — Balance (0–16 points) and Gait (0–12 points) — for a total score of 0–28. It's among the most widely used fall-risk assessment scales alongside Conley, but unlike Conley it relies on direct observation of motor tasks (rising from a chair, standing, walking) rather than history-based questions.

The ASA classification (American Society of Anesthesiologists Physical Status) is the standard system for stratifying preoperative anesthetic risk. It assigns the patient to one of six classes (I–VI) based on overall health status and comorbidities. The ASA class guides the anesthesia plan, intraoperative monitoring, and the level of postoperative surveillance (recovery room, ICU, or ward). It was introduced in 1941 and last updated in 2020.

The Barthel Index (Barthel ADL Index) is the most widely used functional assessment scale worldwide for measuring independence in basic activities of daily living (ADL). It evaluates 10 items — feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, bed-chair transfers, mobility, and stairs — with a score of 0–100 (higher = more independent). It's used in rehabilitation, geriatrics, orthopedics, and long-term care to plan the care plan and discharge.

Italian Law 38/2010 (art. 7) requires all healthcare facilities to assess and document pain in the medical record as the fifth vital sign. It does not mandate a specific scale, but requires recording: the scale used, the score at admission, the trend during the stay, and the results of therapy. Italian nursing federation (FNOPI) guidelines recommend the NRS as first choice in cooperative adults, and FLACC or PAINAD in non-communicative patients.

Fluid balance is calculated by subtracting total output from total intake over 24 hours. Intake = IV infusions + oral intake + enteral/parenteral nutrition + IV medications + blood products. Output = urine output + drains + vomit + NG aspirate + liquid stools + estimated insensible losses (about 700 ml/day in a resting adult, plus 100–150 ml for each °C of fever above 37°C). Balance = Intake − Output.

The Richmond Agitation-Sedation Scale (RASS) is the standard scale for assessing the level of sedation and agitation in adult ICU patients. It measures 10 levels from −5 (unarousable) to +4 (combative), with 0 as the ideal state (awake and calm). The international PADIS 2018 guidelines recommend RASS as the first-choice tool and indicate a standard target of RASS 0 or −1 for ventilated patients.

The Modified Ashworth Scale (MAS) assesses muscle spasticity by assigning a grade from 0 (normal tone) to 4 (complete rigidity) to each muscle group, via passive mobilization of the segment at a constant speed of about 1 second through the full range of motion.