Nursing 105 Risk assessment

Why risk is relevant to nursing care

• Clinical risk management specifically concerned with improving the quality and safety of healthcare services by recognising circumstances that place patients and staff at risk

  • e.g. physical/verbal abuse minimised by more people around

  • back injuries by bending minimised by beds moving up and down

• The fundamentals of care framework identifies patient safety as encompassing physical., psychosocial and environmental safety

Clinical risks

Potential threats to a persons safety and wellbeing during the delivery of healthcare

Risk management aims to maximise and improve patient outcomes by providing care that…

1. assesses and recognises potential risks to patient health

2. prevents, controls, reduces, eliminates or manages identified risks

3. offers proactive rather than reactive approach to care

Current health problems

An actual nursing diagnosis/health problem

e.g. impaired mobility related to spinal cord injury

Potential health problems

an at risk nursing diagnosis

e.g. at risk of impaired skin integrity (pressure ulcer development) due to decreased mobility - can place prevention interventions for potential problems

Pressure related tissue damage

• bed sores

• pressure area

• pressure sore

• pressure ulcer

• decubitus ulcer

Pressure ulcer

Localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, shearing force, friction or a combination of these

Underlying cause of pressure ulcers

Several contributing factors yet underlying cause is compression of soft tissue between a bony prominence and an external surface for a period of time

No patients having falls/pressure injuries indicate…

Good quality care

Mechanisms of pressure related tissue damage

• Interface pressure

• shear

• friction

Interface pressure

The pressure of the body pressing the skin down onto a firm surface

Shear

The pressure that occurs when layers of skin are forced to slide over one another or deeper layers of tissue; can occur when a person slides down or is pulled up out of a bed or wheelchair

Friction

Pressure caused by something, such as a mattress or clothing, rubbing against the surface of the skin

Stage I

• Non blanchable

• erythema of intact skin

Stage II

• Partial-thickness skin loss

Stage III

• Full thickness skin loss; not involving underlying fascia

Stage IV

• Full-thickness skin loss with extensive destruction

Impact of pressure related tissue damage

• Infection - local or systemic

• pain

• cascading spiral e.g. decreased mobility related to pain increases risk of more damage

• decreased quality of life

• increased risk of death

• body image disturbance

• prolonged length of stay in hospital

• prolonged treatment

Extrinsic risk factors

Factors in the immediate environment that create a risk of developing pressure related tissue damage e.g. pressure from a hard surface, such as a bed or chair

• external pressure compressing blood vessels

• friction or shearing forces tearing or injuring blood vessels, skin or subcutaneous tissue

Intrinsic risk factors

• Motility problems - affects ability to move

• poor nutrition - skin needs nutrients to remain healthy

• underlying health conditions disrupting blood supply/make skin more vulnerable to damage

• <70yrs old

• urinary/bowel incontinecne

• altered cognition/consciousness/sensation

Prevention of pressure related tissue damage

• Ongoing assessment/prediction of risk

• Water low pressure risk assessment

• Regular skin assessment

• Maintain nutrition and hydration

• Maintain hygiene

• Continence/moisture management

• Maintain mobility/movement

• Individualised pressure relief plan

• Use skin emollients to hydrate dry skin - don’t vigorously rub skin

• protective dressings for at risk areas e.g. heels

• Regular distribution of body weight off bony prominences

• Minimised shearing force - limit time head of bed elevated

• utilise correct patient handlings techniques - sliding sheets

• equipment provision e.g. alternating air mattress

• educate client + family

• documentation

Falls

An unexpected event in which the person comes to rest on the ground floor or lower level

• people over 65 greater risk

• serious injuries can occur and often require hospitalisation

• Hip fractures most serious fall-relayed injury in people over 65

  • 15% die in hospital, 1/3 within year

  • impacts independence + quality of life

Most falls are caused by the…

Interaction of multiple risk factors

• More risk factors = greater chance falling

Healthcare providers can minimise risks by reducing…

Individuals risk factors

Intrinsic fall risk factors

• Previous fall history

• Age + gender

• living alone

• Comorbidities

• Impaired mobility

• Psychological status

• Nutritional deficiencies

• cognition

• visual impairments

Extrinsic fall risk factors

• Poor lighting

• slippery floors

• uneven surfaces

• cluttered living space

• inappropriate walking aid

• poor footwear and clothing

Falls risk assessment - hospital

Must be done 24 hours before patient admission

• Previous falls

• Physical  health - mobility status

• Neurological -cognitive status

• Communication abilities (especially in healthcare setting)

• Toileting / continence

• Medications

• Age

• Sensory impairment

• Environment

• Tethers e.g. Intravenous lines

• Un-familar environment

Falls risk assessment tools

• Morse falls risk assessment Regular skin

• FRAT (falls risk assessment tool)

Because falls risk assessment tools cannot be relied upon as definitive predictors of whether a patient will experience a fall or not, these tools should…

complement clinical judgement, not replace it

Falls risk interventions

• Environment safety and management

• patient/ client education

• Elimination needs managed

• Medications reviewed

• Mobility assistance / supervision

• Equipment e.g. walking aids

• Ensure falls assessment tool is current

• Appropriate and individualised plan of care

• Collaborate with the MDT

Benefits of bed rails

• Reminds patient they are not in usual environment

• provide a feeling of comfort + safety

• patient can use rails when turning in bed

• reduce fall risk/injury transporting

Bedrails controversial as…

• can be considered form of restraint

• associated with injury and death (patients trying to leave bed without assistance)

Low beds

• Can be lowered to floor level

• Can reduce falls and fall related injuries

• Can be used to facilitate  safety and independence in patient transfers (height of bed can be adjusted to  meet patient needs)

• However, can be a form of restraint if patient unable to get up from floor level

Other common risks

• Risk of postoperative complications such as Deep Vein Thrombosis (DVT)

• Risk of malnutrition

• Risk of dehydration

• Risk of depression

• Risk of self harm

• Risk of constipation