Assessment of risk and the medical patient

6 Assessment of risk and the medical patient




Introduction


Life is full of risks and we are constantly making risk assessments for ourselves without realising it. Each time you get into a car to drive, you are unconsciously making an assessment of risk: is it safe to drive to my destination, do I have the skills and knowledge to drive, will I be tired, is the weather good, do I have an alternative way of getting to my destination? Making these sorts of risk assessments for ourselves becomes a part of life that we rarely spend any time thinking about.


Patients with a medical health problem may be at risk in a number of ways, such as the risk of developing a pressure ulcer, of falling, of abuse. Part of your role as the nurse caring for a medical patient is to assess their risk and plan their care accordingly. These risks will apply in any setting the medical patient is in, so risk assessment will be an essential skill to learn wherever your placement learning experience may be.


Within your curriculum you will have a number of competencies and/or learning outcomes around risk assessment and safeguarding. This chapter aims to help you identify the essential knowledge and skills required to meet these learning outcomes and be able to identify opportunities within your medical placement to do this. The Essential Skills Clusters (Nursing and Midwifery Council (NMC) 2010a) include competencies around risk assessment and safeguarding vulnerable adults, organisational aspects of care, infection prevention and control and nutrition and fluid management.


The NMC (2010b) Domain ‘Professional Values’ is relevant to risk assessment and safeguarding. For example, the competencies include the following:



There are also aspects of the domain ‘nursing practice and decision making’ that apply to risk assessment and safeguarding. For example, the competencies include the following:




What is risk assessment?


Risk assessments are a way of identifying potential problems your patient may have so that actions can be put into place to prevent these risks occurring. For example, if you identify that your patient is at risk of falls, you can put into place a plan of care to reduce their risk of falling.



It is also worth asking whether the risk assessment is locally driven or a nationally driven assessment. For example, is it linked to national best practice guidelines such as those developed by the National Institute for Health and Clinical Excellence: http://www.nice.org.uk/ (accessed July 2011)?


Most of the risk assessments you will have found will be standardised instruments that have been locally or nationally validated. The validity (that it measures what it sets out to measure) and reliability (that it consistently measures what it sets out to measure) of a tool is important as it helps you to know that the results of the risk assessment can be relied upon.




Examples of risk assessment tools


The following are examples of the kind of risk assessments you may find and some of the validated tools that are in use:



Different risk assessment tools will apply at different stages of your patients’ journey. Some of them will be common across all stages of the journey (Box 6.1).



Some risk assessments are tied to statutes, for example manual handling. You should have received training in moving and handling patients before you commenced your clinical placement, and some of you may have found that you were not able to commence your placement until this was completed. Check with your university to find out their requirements and provision of manual handling training.



How are risk assessment tools developed?


The assessments are often based on evidence-based factors that contribute towards a certain risk. These factors are then given a numerical value which will give a total value at the end of the assessment and this helps you to decide the level of risk your patient is at.


It is important that you understand why certain factors put some people at an increased risk. Spending some time looking at a tool and working out how risk factors are determined is a useful exercise. Look at the Waterlow score (Waterlow 2005) in Figure 6.1 for assessing risk of developing pressure ulcers. Think about each category of risk and why such factors contribute to the development of pressure ulcers – you will need to think back to anatomy and physiology. Table 6.1 describes what each of the categories for risk within the Waterlow score mean.



Table 6.1 The categories for risk within the Waterlow score




































Risk factor How it contributes to pressure ulcer development
Build/weight for height Being overweight restricts your mobility and consequently your ability to relieve the pressure on parts of your body when sitting or lying down. Being underweight reduces the subcutaneous fat that protects your bony prominences from increased pressure
Skin type If skin is dry it is much more likely to crack and damage easily. Tissue paper skin is thin and more easily damaged. Skin that is stretched over oedematous areas is also thinner and more easily damaged. Oedema will also reduce the blood supply to the skin surface. Discoloration is a sign that damage has already occurred. Skin that is clammy or damp is more susceptible to friction and shearing forces
Sex/age Skin loses its elasticity as it ages and a reduction in blood supply to the skin surface means that it will take longer to heal
Continence Wet and soiled skin from incontinence can become easily excoriated, increasing risk of skin breakdown. It also makes the skin more susceptible to friction and shearing forces
Mobility The less able a person is to move, the less able they are to relieve pressure when sitting or lying down
Tissue malnutrition There are many conditions that contribute to a reduced perfusion and blood flow to tissues and reduced overall mobility of the patient. These will all increase the risk of skin breakdown and delay healing
Neurological deficit A condition that results in a sensory deficit will mean the person is unable to fully feel pressure or pain and therefore will not change position to reduce pressure
Major surgery or trauma The prolonged period of immobility associated with major surgery or trauma increases the risk of pressure damage
Medication Medication that reduces the body’s own inflammatory response will affect the skin’s ability to heal
Nutrition Being underweight, having significant weight loss and a poor appetite all contribute to an increased risk of acute illness and immobility and a reduced ability of the skin to heal

But risk assessment is not just about completing a risk assessment form. You must know what actions to take depending on the results of the assessment. Many widely used forms will have guidance about how to interpret the results and the actions you need to take, but these may not always be obvious if you have not used the tools before. Again, ask your mentor about this and do some reading around the tool to help you understand its significance to your patient.


It is also important to know the limitation of the risk assessment you are carrying out. You must always use you clinical judgement as well as the risk assessment. If the tool is telling you there is no need for concern, but your clinical judgement is telling you otherwise, then always follow your judgement and take whatever action is necessary to safeguard your patient.


The popularity of risk assessment tools also changes and new evidence may show that some well used tools are not as useful as they have been. Examples of this are falls risk assessment tools. Recent evidence has shown that they are not absolutely necessary in the prevention of falls for patients in hospital and that an assessment of modified risk factors should always be carried out with or without a numerical risk assessment (NPSA 2007b).



You may have considered that Mrs Kalra(see case history 6.1) would need a nutritional risk assessment as she is not eating and drinking well at present. As her mobility is reduced, she would require a manual handling risk assessment to determine the safest way for staff to help her mobilise, reducing the risk of injury both to Mrs Kalra and nursing staff. She may also be at risk of falls due to her confusion, dehydration and poor mobility so a falls risk assessment would be necessary. She already has a grade 2 pressure ulcer and her reduced mobility and oral intake will put her at risk of developing further pressure ulcers, so a pressure ulcer risk assessment would be required to help guide your management of her pressure ulcer risk. She is about to commence intravenous fluids, so her intravenous cannula site would require regular assessment for early detection of phlebitis or other complications.


One major consideration in your assessment and management of the risks that Mrs Kalra may face is her limited ability to understand and speak English. You will need to consider the best way to communicate with Mrs Kalra. Initially this may be with the help of a bilingual advocate or a member of her family, but on a daily basis you may need to rely heavily on visual prompts and cues. You will also need to get detailed information from her family about her usual routine, likes and dislikes as this is an important aspect of delivering person-centred care for a person with dementia.


Use this opportunity to improve your knowledge about caring for people with dementia in a hospital/intermediate care setting. The following two articles by Dewing describe some of the challenges of caring for people with dementia in an acute setting and an intermediate care setting along with suggestions about how nursing care for such patients can be improved.


Feb 25, 2017 | Posted by in NURSING | Comments Off on Assessment of risk and the medical patient

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