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Safety Screening – Admission History Assessment (Nursing)

by Samantha Rhea

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    00:04 Now, when we talk about admission history, we talked a lot a little bit about travel screenings and things like this, but safety screenings are a biggie when we talk about admission history.

    00:15 As you can see here on the slide, there's a lot of safety screenings that we will have an interview process or a conversation with our patient and we're going to discuss each one of these topics and that will trigger really important resources for that patient, if they deem necessary.

    00:32 Let's take a look at this first one. This is the palliative care screening.

    00:37 Now, this is a consult for patients, for family, for support; and this really has to do with any life limiting or life threatening conditions.

    00:47 It also really does a great job of establishing goals of care.

    00:51 Now one thing to note before we move off of this, many times we consider this what we call hospice care meaning end of life.

    00:58 That's not the case here in regards to palliative care.

    01:02 We're making goals with either life-limiting or life-threatening condition.

    01:07 Now, let's talk about sepsis screening.

    01:11 This is one that is universal throughout because of new evidence.

    01:15 Now sepsis is a bad thing.

    01:17 This is a small infection that gets really big and sometimes it starts from a small infection and it goes higher and higher and more adverse, and the patient could eventually go into the ICU or intensive care because of this.

    01:32 Now, when we do a sepsis screening, we're going to look for any known or suspected infections.

    01:37 We're going to definitely look at those patient's vital signs, like are they having a high temperature or low temperature? Is there heart rate high? Is there respirations high? We're going to look at key laboratory values such as white blood cells for example.

    01:52 And also patient's symptoms, are they having any sort of cough or icky weird infected looking sputum? Any sort of odd things that are coming out of the patient's urine like dark urine or blood or white or any sort of discoloration that could lead to infection? And of course, we're going to look at all of these factors at any sort of patient's line or device that they have in place.

    02:17 Now, let's take about another really important type of screening which is the suicide screening.

    02:23 Now this should be applicable to all populations, not just certain high risk populations and as a nurse, I want you to keep that in mind.

    02:31 Now this is really important in regards to patient's safety and again I know these are hard questions to ask, but, your facility has a specific set of questions much like this, that is a validated evidence-based tool in regards to the most appropriate suicide screening questions.

    02:51 So you may see questions like this, do you wish you didn't have to go on living? Or have you had thoughts of wanting to die? Have you thought of harming yourself? And a really important one, is do you have a plan? Now that last one is especially if you note when you're screening an individual and they have that, they say yes to that last point, that one is a really key indicator that we may need to put specific suicide precautions in place.

    03:21 So when we talk about suicide precaution, the interventions are going to come from the physician, but many times this is going to include one on one observation for example.

    03:31 Certain type of monitoring.

    03:32 It could be that we remove excess linens and belongings out of that patient's room as well.

    03:38 Now, next stop is skin screening.

    03:40 This is really important to have a baseline skin assessment and that's needed on admission.

    03:46 Now we asses this on our initial physical assessment, but we want to screen as well and document any wounds to trigger consults for the care of our patients.

    03:56 So when you talk about skin screenings, so very important to document any pressure ulcers, any wounds, any lacerations when the patient comes to us at our facility.

    04:09 Now it's important that we document this on admission, because if the patients comes in with this, then we do not own that wound, meaning we did not cause this while they were in our care, so it's important to screen here and to consider all these points in regards to skin.

    04:26 So many times on a skin screening you may see the word abraded for example, that's a very popular skin screening that includes these points.

    04:34 So the first one if you see here is sensory perception.

    04:38 So if we're talking about peripheral arterial disease or diabetics, they may have a loss of sensation and that's important to note because they could be at high risk for skin integrity issues.

    04:50 Now another one here is moisture, that's a big one. If the patient's incontinent for example.

    04:56 As you can imagine that can cause skin issues as well.

    04:59 As long as, along with activity, can the patient do their normal activities and ADL's? Can the patient may be mobilize or move back and forth to the bathroom and ambulate on their own? Do they have substantial nutrition to support their skin integrity? And, while they're immobile or they're in bed, is there potential for any friction or shear across that bed linen that could cause skin issues? Now with the screening tool, we look at all of these pieces and if they're at high risk and we assess this, it will trigger our wound consult.

    05:33 Now let's talk about nutrition screening.

    05:37 Now this is the status that determines disease progression, again wound healing like we talked about, and if the patient is susceptible to any sort of pressure ulcers while they're in our care.

    05:47 So screenings going to include things like have you had any unexplained weight loss or weight gain? Any decreased appetite over time? Any issues with swallowing or chewing? Now if you have any of these issues, this will also trigger a nutritionist and a consult for our patient.

    06:05 Now, when we are discussing fall risks, this is one of the biggest causes of injury or mortality in the hospital setting.

    06:13 And note that falls are a 100% preventable, so we've got to be diligent about looking and screening for fall prevention with our patients.

    06:22 So when we talk about screening, it's going to include these main points such as the fall history, meaning, has your patient fallen within the last six months? Now if they have and this is a yes, this can deem them high risk for falls and therefore, we want to incorporate appropriate interventions for safety for the patient.

    06:42 And, next, don't forget about the elimination needs of your patient.

    06:45 If they need frequent toileting, they have urgency, they have incontinence issues, this can also deem them high risk for falls.

    06:54 And of course, there mobility.

    06:56 Now, if a patient can ambulate independently back and forth to the bathroom, their risk of falling is much less than maybe someone that needs a cane or a one-person assist getting to the bathroom.

    07:09 Mental status plays a big part of fall risks, so if their patient is confused for example, has hospital delirium, this can contribute to falls along with the biggie is medications, all the medications that we give to that patient.

    07:24 Now, let's look at the topic of medications.

    07:27 As you can imagine, a lot of things that we give to the patient can contribute to falling, that can include sedative, narcotics, diuretics, laxatives for example, and all of these points that you see here, if the patient is deemed high risk for falls, we need to look at these specific topics and also set a specific set of interventions for the patient, so that can include things such as a yellow wrist band that says to all staff members, all healthcare providers, that they are indeed high risk for falls.

    08:00 That could be a sign outside the patient's door that they're high risk for falls and of course, those wonderful, yellow non-flip socks.

    08:08 Now, another important screening tool is the abuse screening tool.

    08:13 Now, so this is another very difficult topic for healthcare providers and nursing staff, but these questions are so important such as making sure you screen your patient for signs of abuse.

    08:26 Now this could include, do you feel unsafe at home, work, or school? Also, do you feel threatened by someone? Now as a nurse, when we're asking these questions, we want to be assessing our patient.

    08:38 Do you see the patient maybe guarding or not wanting to make eye contact? Do you see different bruises at various stages of healing? These are all things to consider when we're talking about abuse screening with our patients.

    08:52 Here is another thing.

    08:54 Many times as nurses, we may go through the motions when we're asking these questions, but think about the environment the patient's in and who's with the patient.

    09:03 Now, if the patient's at risk and the person that is providing the abuse is with the patient, it's probably not the right time to screen, so please, be diligent and keep this in mind when you're doing the screening.

    09:16 Now if there are any yeses to any of these questions, this could contribute to a trigger to consult for social services.

    09:24 This could be either adult or child protective services may need to be contacted.

    09:29 Now next stop is substance abuse screening.

    09:33 Now this can include anything such as tobacco history, substance abuse history and alcohol screening.

    09:40 Now, we need to do this screening and this is really important because this can affect different parts of their care and also the treatment they provide.

    09:49 So it's important that you have this conversation with your patient in a nonjudgmental manner.

    09:55 Now also note that due to the screening, that patient may need to be monitored for certain withdrawal symptoms, and as healthcare providers, we need to be alerted to this.

    10:05 Now looking at the importance of holistic view point of your patient, don't forget that the spiritual screening is also very important.

    10:14 Now, when we're talking about spiritual screening, this is typically going to include spiritual, cultural, religious beliefs and practices, that may affect their particular care.

    10:26 Now, some of these questions may include, do you have any beliefs such as spiritual, cultural, those religious beliefs or practices that may affect their care.

    10:35 Now, this could be food choices or specific medications or treatments.

    10:40 You also may ask your patient if they would like a visit from the hospital chaplain during their stay.

    10:46 So one thing to note in a very common trigger or very common screening that comes up is some religious preferences do not believe that receiving blood products is appropriate for their particular beliefs, so that's really important to screen as appropriately, because if the patient needs surgery, we need to know this beforehand.

    11:07 Now, let's talk about the functional ability of our patients.

    11:11 So we have a disability and function screening build-in to our admission history assessment.

    11:16 Now this is going to include things such as sensory limitations, communication difficulties, mobility issues, and the use of certain types of medical equipment.

    11:28 Now this is important because what if the patient is hard of hearing? They have glasses? Maybe they have difficulties with walking or climbing stairs or just that they use a cane at home.

    11:39 All of these are things are important, so that the patient can be as independent as possible while they're under our care.

    11:45 And just note that if there's a yes to any of these issues here, that they may consult physical therapy, occupational, or even speech therapy.


    About the Lecture

    The lecture Safety Screening – Admission History Assessment (Nursing) by Samantha Rhea is from the course Admission History Assessment (Nursing).


    Included Quiz Questions

    1. Do you have a plan to kill yourself?
    2. Do you have a desire to end your life?
    3. Are you sad?
    4. Do you often think about harming yourself?
    1. A client who is experiencing diabetic neuropathy and incontinence
    2. A client who uses a walker and often shuffles their feet when ambulating
    3. A client diagnosed with anorexia and has increased urinary urgency
    4. A 30-year-old client, diagnosed with a spinal cord injury and is now bed-bound
    1. Falls risk screening tool
    2. Sepsis screening tool
    3. Suicide risk screening tool
    4. Pressure injury screening tool
    1. Falls prevention
    2. Nutrition assessment
    3. Abuse screening
    4. Disability/function screening
    5. Immunization screening
    1. Find an opportunity to speak to the client alone so that the nurse can perform a thorough abuse screening.
    2. Ask the client if their partner is abusing them.
    3. Ask the client where the bruises are from.
    4. Assume the partner is abusing the client and ask social work to see the client.
    1. Septic shock
    2. SIRS
    3. Severe sepsis
    4. Systemic infection

    Author of lecture Safety Screening – Admission History Assessment (Nursing)

     Samantha Rhea

    Samantha Rhea


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