Risk Assessment Tools In Nursing – The Braden Scale and the Norton Scale have been tested enough to be useful adjuncts to nursing assessments and care planning. These tools, along with clinical judgment, increase the ability to identify risk factors that are then incorporated into a client specific prevention plan of care. Ideally, the client should be assessed for risk on admission, again in 48 hours, and as often as the level of morbidity indicates.
Site of care assessment schedule:
- The potential for a client to develop a pressure ulcer may be influenced by intrinsic risk factors that relate to aspects of the client’s physical, psychosocial, or medical condition.
When conducting a risk assessment, the following elements should be taken into account:
- Extrinsic factors derived from the environment can also influence the development of pressure ulcers. These factors include: nutritional status (malnutrition and dehydration), reduced mobility or immobility, repetitive stress syndrome (involuntary movements), posture/contractures, neurological/sensory impairment, incontinence (urinary and fecal), extremes of age, level of consciousness and acute illness.
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List Of Risk Assessment Tools In Nursing
Nurses use a variety of clinical risk assessment tools to assist with patient care in the clinical setting. They are:
- The Braden Scale which is used to forecast the risk of pressure sores.
- Falls Risk Assessment which is used to figure out how likely it is for someone to fall such as STRATiFY (Oliver et al., 1998) and Morse (1997)
- Tools for Clinical Risk Assessment Tools are specific tests that are used to determine the degree of risk associated with particular situations, procedures, and outcomes.
- Assessment of bed rails such as the National Patient Safety Agency devices.
- Risk assessment for pressure ulcers such as Waterlow.
- Risk assessment for malnutrition such as the Universal Screening Tool for Malnutrition
- Control of infections such as the Visual Infusion Phlebitis score for identifying phlebitis symptoms.
- Early warning scores such as the Modified Early Warning score which are used to identify patient deterioration. At various points along your patients’ journey, different risk assessment tools will be utilized.
- A basic screening tool known as the Alcohol Use Disorders Identification Test (or AUDIT) is used to detect the early signs of dangerous and harmful drinking, mild dependence and the need for assisted withdrawal. Most adult men and women over the age of 20 can calculate their body mass index (BMI), which is a measure of body fat based on height and weight in relation to height.
- To make sure that sepsis bundles are followed, BUFALO assessments are used.
- The 21-item Beck Depression Inventory, also known as the BDI, is a rating system that measures typical attitudes as well as symptoms of depression.
- The Bed Rails Assessment is a tool for evaluating the risk of using bed rails with a patient.
- The Catheter Assessment is a check to see if the device is still needed, if a fixation device is used, and if the catheter bag is still in good condition.
- Cubbin & Jackson is used to predict the risk of developing a pressure ulcer in critically ill patients, most of whom are in intensive care. It estimates the chances that a patient will develop a pressure sore.
- The Confusion Assessment Method, also known as CAM, is designed to aid in the identification of delirium or confusion symptoms.
- The confusion assessment method (CAM) tool has been adapted for use with ICU patients.
- A set of criteria known as the centor score can be used to determine whether or not an adult patient with a sore throat has a bacterial infection.
- A screening tool for CRE (Carbapenem Resistant Enterobacteriaceae) is the CRE Assessment.
- DisDAT is designed to help people who have severely limited communication due to cognitive impairment or physical illness identify distress cues.
- The early warning score, also known as EWS, MEWS, NEWS, or PEWS, is a tool for quickly determining a patient’s level of health. The six major vital signs serve as its foundation; Temperature, blood pressure, heart rate, and AVPU / GCS response are all measured. Urine output is also included in some scores.
- The face, arm, and speech test, or FAST, is used to evaluate a patient’s stroke-like symptoms.
- The FRAX tool was created to assess patients’ fracture risk. It is based on individual patient models.
- A behavioral pain assessment tool known as FLACC—face, legs, activity, cry, and consolability—is intended for pediatric or nonverbal patients.
- The Glasgow Coma Scale (or GCS) is a neurological scale that aims to provide a reliable and impartial method for recording a person’s conscious state for initial and subsequent evaluation. A patient’s score is determined by comparing them to the criteria of the scale, which ranges from 3 (indicating deep unconsciousness) to 14 (the original scale) or 15 (the more commonly used modified or revised scale). The Glasgow Depression Scale was developed to assess patients with learning disabilities’ mood and the likelihood of developing depression.
- In ACS (acute coronary syndrome), which includes n-stemi, stemi, and unstable angina, the Global Registry of Acute Coronary Events (or GRACE score) score is used to assess risk.
- The Generalized Anxiety Disorder Questionnaire, also known as the GAD-7) is a screening tool that is used to determine how severe a person with GAD is. Patients are seen and evaluated at least once an hour. It is beneficial for patients with dementia, delirium, or children who are unlikely to seek assistance.
- The Hospital Anxiety and Depression Scale, also known as the HADS, can be utilized in both the community and the hospital for anxiety and depression.
- A risk assessment called a MRSA Assessment (Methicillin-resistant Staphylococcus Aureus) is used to determine a patient’s MRSA risk status and whether decolonization is required.
- Body language and verbal responses are used to assess an infant’s pain, agitation, and sedation levels with the Neonatal Pain, Agitation, and Sedation Score (or N-PASS), typically in neonatal intensive care units. A useful tool for accurately describing, assessing, and documenting a patient’s pain is PQRST (provocation/palliation, quantity/quality, region/radiation, timing). Additionally, the method aids in selecting the appropriate painkiller and assessing the patient’s response to treatment.
- The two-stage capacity test is used to determine whether a person can make a specific decision. It consists of two questions:
- Stage 1. Is a person’s mind or brain affected in any way or is there a disturbance in how it works?
- Stage 2. Is the person’s impairment or disturbance severe enough to render them incapable of making a specific choice?
- Traffic Light Assessment is a tool for children or patients with learning disabilities to help them tell staff members about their likes, dislikes, and preferences.
- An assessment known as a venous thromboembolism evaluation (VTE) is used to determine a patient’s chances of developing a deep vein thrombosis (DVT).
- The Safer Nursing Care Tool also known as Safer Staffing, Acuity, Dependency is designed to assess patients’ dependency and any necessary interventions to guarantee adequate and safe staffing levels.
- SBAR which stands for Situation, Background, Assessment, and Recommendations provides a methodical means of evaluating and communicating care. A variant of the SBAR framework is called SBEAR (Situation, Background, Examination, Assessment, and Recommendations).
- The Supportive & Palliative Care Indicators Tool (SPICT) is used to identify individuals with one or more advanced conditions who are at risk of deterioration and death, primarily used to assess and plan for palliative care needs.
- One of the many sedation scales utilized in medicine to assess a patient’s agitation or sedation level is the Richmond Agitation-Sedation Scale (RASS). The Ramsay scale, the Sedation-Agitation-Scale, and the COMFORT scale for pediatric patients are two additional tools.
- The WHO Checklist includes team introductions, verifying the identity of patients, confirming the proposed operation, and consent forms. It was created to reinforce established safety practices and improve communication and teamwork among clinical teammates.
- The Wong-Baker FACES Pain Rating Scale is a pain assessment tool based on a group of faces that represent various emotions.
- The Wells criteria are used to determine the risk of pulmonary embolism or deep vein thrombosis.
- The vital instrument known as the visual infusion phlebitis score (or VIPS) makes it easier to promptly remove short peripheral intravenous catheters at the earliest signs of infection.
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A mnemonic acronym called SOCRATES is used by medical professionals to determine the nature of a patient’s pain. It asks the following questions:
- Where is the discomfort? or where the pain is most intense.
- When did the pain begin, and was it sudden or gradual?
- Whether it is regressive or progressive as well.
- How does the pain feel? A pain? Stabbing?
- Where exactly does the pain radiate?
- Are there any additional signs or symptoms that are connected to the pain?
- Does the pain have a pattern?
- Does anything alter the pain?
- How much pain is there?
These tools and many more would help the nurse not to pick tools randomly.