RB.S.(n) Clinical Pearl: Nursing Assessment Red Flags

Learn nursing assessment red flags to anticipate patient needs and keep your patients safe.

Last updated: September 15, 2023

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Nursing assessment red flags are early warning signs of something more serious. Sometimes they are obvious, other times they are difficult to spot.

Below, we give you some key nursing assessment red flags to be on the lookout for when assessing your patients. Red flags are organized by system in a head-to-toe format.

Keep reading to learn common red flags and for an easy to understand nursing assessment red flag infographic.

What Are Nursing Assessment Red Flags

Red flags are signs and symptoms of a serious, emerging or overlooked health condition. Often, red flags are warnings of a change in your patient’s status.

These findings should never be ignored and require further investigation. If you are ever unsure of a clinical finding, you should alert a colleague to double check your findings or alert the responsible physician as soon as possible.

If you’ve ever had that gut feeling that your patient is going “downhill” even though their vital signs are completely normal, you’ve probably picked up on some red flags without even knowing it.

Nurses who haven’t had that feeling, don’t worry, you will. As you get more experienced it is almost as if you develop a sixth sense for spotting red flags and changes in your patient’s condition.

Keep reading for a list of common red flags for each system.

Nursing Assessment Red Flags Infographic

Nursing Assessment Red Flags Infographic

Nursing Assessment Red Flags by Body System

Neurological:

  • Meningeal irritation – nuchal rigidity, Kernig’s sign, Brudzinski’s sign
  • Confusion or change in level of consciousness
  • Slurred speech
  • Vision changes
  • Loss of bladder or bowel function (new onset)
  • Difficulty walking
  • Numbness following a head, neck or back injury
  • All headaches of acute, severe onset
  • Asymmetrical pupils

HEENT

  • Asymmetrical facial movements
  • Headache described as “the worst headache of my life”
  • Diplopia, flashes, floaters or presence of a shadow or curtain  in visual field
  • Photophobia
  • Recurrent epistaxis
  • Sore throat with difficulty swallowing, drooling or muffled voice
  • Displaced uvula
  • Enlarged lymph nodes
  • Neck stiffness

Respiratory

  • Deviated trachea
  • Signs of distress – nasal flaring, pursed-lip breathing, cyanosis of the lips, or diminished respiratory effort
  • Accessory muscle use
  • Tripoding
  • Paradoxical breathing
  • Cyanosis of the lips/mouth
  • Hemoptysis

Cardiac

  • Extreme hypertension,
  • Increased JVP
  • Persistent or unexplained tachycardia
  • Swelling or edema
  • Palpitations
  • Syncope/Presyncope
  • Chest pain
  • Cool limbs

Musculoskeletal

  • Signs of cauda equina – back pain with urinary retention and/or stool incontinence

Mental Health

  • Delirium
  • Suicidal or homicidal ideation
  • Signs of psychosis – auditory/visual/tactile disturbances

Summary

Attuning yourself to nursing assessment red flags will help you better anticipate your patient’s care needs.

Every body system has different red flags to be on the look out for. Use the list above and our infographic to review important nursing assessment red flags.

For new nurses, this can seem daunting. Eventually, however, recognizing important red flags and knowing what to do about them will become second nature.

Experienced nurses with good “red flag” radar can use the list or infographic above as a review. Share it with other nurses or new nurses looking for a resource.


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