Safety in the Acute Care Setting: Screening (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 All right. So one way to reduce the potential risk to the client is using screening tools.

    00:07 We use a screening tools all the time in the hospital.

    00:10 This is another form of assessment that we like to use.

    00:13 So the nice thing is by using these screening tools, it will prompt us as the nurse to put specific interventions in place.

    00:21 So one of the most common screening tools you're going to do is a fall risk assessment.

    00:26 This is actually something I have my nursing students do currently.

    00:30 So major falls are one of the biggest issues that we deal with in health care and can definitely lead to poor patient outcomes.

    00:37 So something to think about is, how weak is your patient? What if you try to even have them lift their arm and they can't even do that? That can be a potential problem if the patient tries to get up.

    00:48 The other thing to think about is, what do you think about all those meds that we give to the patient? Sometimes we pile those on, we're not really thinking about all the full effects.

    00:58 What about even anesthesia after surgery? I know I've gotten my teeth taken out and after anesthesia, I'm not walking the straightest.

    01:06 The other thing also to consider is what about how impulsive the patient is? Now you'll be maybe like, What are you talking about, impulsive? Well certain diagnosis such as stroke, they have a certain part of their brain that can be damaged because of the stroke, so they tend to be more impulsive in their actions.

    01:22 So something to think about as a nurse.

    01:25 Also, what about all those lines we attach to them? You think sometimes like how can they get around with stuff attached their feet, to their arms, maybe even both arms? You can imagine all these lines are something that they could trip on and fall.

    01:41 Also, what about them needing maybe wheelchairs? or maybe needing some sort of transfer equipment to get from point A to point B? One of the other things besides fall is skin breakdown.

    01:53 I cannot get on attention enough about skin breakdown, this drives me crazy.

    01:58 This is such a preventable thing that we can do in the hospital as nurses, and therefore we have a great screening tool for it So one of the popular ones is called the Brighton and we're going to look at different facets to keep that patient's skin intact.

    02:13 So one of them is their sensory perception such as, can they even feel maybe their bottom or their leg? Or can they feel anything in case they start getting a wound? So we're going to look at their sensory perception.

    02:26 Also, what if that patient's incontinent, meaning they do not have control of their bowel and bladder.

    02:31 And if they have this issue, all of those fluids in contact with your skin can quickly, very quickly break down your skin.

    02:40 Is the patient even able to get up out of bed? So if I'm standing here or laying in bed for several hours, all those pressure points you can imagine can definitely break down your skin.

    02:51 They say it only takes about a couple of hours, maybe even less to start a pressure sore.

    02:57 Same thing with mobility.

    02:59 You know, can they even move their arms? Can they turn in the bed, this is something we really got to consider.

    03:06 So a lot of the times we will develop what we call 'turn teams', meaning we move the patient from side to side every couple of hours to offload that pressure to prevent those pressure sores.

    03:18 Also, nutrition.

    03:20 Now we all love to eat, nutrition's important.

    03:23 But one thing we need to consider is is good proteins, good calories.

    03:27 Good nutrition is also gonna help that patient be better for their wound and it's gonna help them prevent skin breakdown.

    03:36 Also, when we're moving a patient, let's say they have a mobility issue like we're trying to slide them up in bed.

    03:43 You can imagine any shearing across those sheets can definitely rub against someone and tear down skin that's possibly weak or malnourished, or maybe has some moisture issues.

    03:55 So friction and shearing a patient's skin can definitely put them at risk.

    04:01 So depending on your setting, you may have a sepsis screening tool.

    04:05 So sepsis is a really bad infection.

    04:09 It's a bad deal, and it can make a patient really sick.

    04:12 Typically when you see sepsis, it's gonna be in the intensive care unit and we definitely want to avoid this.

    04:18 So we use a screening tool that looks at patients' lab data, and their vital signs.

    04:25 And there are several screening tools out there.

    04:27 Some of the main ones that you're gonna see the most common are the fall risk, the skin breakdown tool, also you may even see a suicide risk assessment.

    04:37 And remember, maybe in those adolescents, for example, because they're at risk, maybe even a depression screening.

    04:44 What about an alcohol withdrawal assessment? Sometimes we need to assess that to keep our patients safe, and so they can detox safely.

    04:52 And nutritional assessment, and also a bone fragility score.

    About the Lecture

    The lecture Safety in the Acute Care Setting: Screening (Nursing) by Samantha Rhea, MSN, RN is from the course Safe and Effective Patient Care (Nursing).

    Included Quiz Questions

    1. A client who just received morphine intravenously
    2. A client who has two antibiotics infusing into two intravenous sites
    3. A client who keeps getting out of bed without asking for help
    4. A client who is incontinent of bowel and bladder
    5. A client who reports having little motivation to get out of bed during the day
    1. Ensuring incontinent client's groin is clean and dry
    2. Assessing sensory perception
    3. Providing a diet high in carbohydrates
    4. Moving as little as possible
    5. Repositioning client once a day
    1. To identify which clients are at risk for an injury or complication
    2. To fix problems that resulted from poor safety
    3. To identify clients who are at risk for psychiatric emergencies
    4. To suggest methods on how to prevent safety complications

    Author of lecture Safety in the Acute Care Setting: Screening (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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