Risk Assessments

 Ahh I love filling out a good risk assessment
– said no nurse ever

Now this isn’t strictly true, but more often than not they can be seen as a hindrance or excessively time consuming, so I wanted to talk a little bit about why they exist, what they’re for and their importance.

What are they?

Risk assessments are a staple part of nursing care and can range from simple nutrition or falls assessments to more complex mental health reviews. Every single assessment has their own little purpose, and some will be more appropriate at one time rather than another. All hospitals and trusts will have their own in-house assessments that they require staff to complete, although the majority of them will be very similar.

These wonderful documents give you a score on ‘risk’ which is defined as “the possibility that something unpleasant or unwelcome will happen” and can therefore be a really useful tool to help give nursing care. They can help highlight actual or potential medical or psychological conditions and can give clear guidance on how a healthcare professional should act depending on the outcome.

Why are they so important?

Simply because they provide a good baseline of care for a patient.

Take the MUST tool: this is a super simple little nutrition and weight assessment that can be completed with very little information, can be applied to most patient groups, is very quick to do and gives a robust result that’s easy to interpret (Malnutrition Advisory Group, 2003). The MUST tool can be utilised in nearly every environment (and has been tested in most) and has good results in relation to mortality and morbidity (Kondrup et al., 2003).

They can also be an excellent way of comparing a patient’s progress or decline, getting a baseline view of that particular goal that can be matched against future assessments. This can be usefully in pretty much any scenario: have they put on weight? Has their cognitive function declined? Is their incontinent worse?

It also allows patient care to be standardised, ensuring that every patient entering that hospital is all being screened in the same way for the same issues. This primarily prevents things from being missed by clinical staff and is something I’ve found particularly useful during my training while I got to grips with all the thousands of questions that I need to ask someone on admission (Dougherty, Lister and West-Oram, 2015).

The faults

Risk assessments are tools, and like all tools they have a window of usefulness. In some circumstances, something like MUST will be excellent to give a quick clinical picture, but because of its simplicity it will miss patients or give an inappropriate result and pathway (Malnutrition Advisory Group, 2003; Volkert et al., 2015). They are not a substitute for good clinical judgement.

Some examples

Nutrition – malnutrition universal screening tool, mini nutritional assessment, body mass index
Falls – falls risk assessment tool
Continence – catheter, urinary, bowel
Skin integrity – waterlow, Braden’s, Cubbin and Jackson’s
Cognitive function – Addenbrooke’s cognitive examination, confusion assessment method
Neurological – AVPU, FAST, Glasgow coma scale
Sepsis – BUFALO
Vascular – VTE
Pain – 1-10, 1-5, PAINAD

These are only a taster of the assessments available and different areas and practitioners will have their favourites. NICE will often include the best validated assessments in their guidance.

When are they done?

Most commonly on admission to hospital or during a first contact; this gives the healthcare team a good clinical picture of the risks for that individual. It is often useful to redo assessments following a clinical change in the patient to allow the risks to be reevaluated. There are times when doing an assessment isn’t appropriate, for instance doing a mental health assessment when the patient has an infection, and then you have to wait for the issue to be resolved before reassessing.

The legal stuff

I’ve only worked in two trusts (and one private nursing home), but all of these had a set of risk assessments that were compulsory for care staff to complete on admission to hospital or on first contact. Now, while some people may consider these to be unnecessarily time consuming or pointless, you need to remember that not only are they important for patient safety, but they are also legal documents. If your hospital policy states that they have to be completed accurately and acted upon, you gotta do it.

So what?

While sometimes it might feel that these assessments were concocted by some higher power simply to disrupt your day, they exist to promote patient well being and safety, so you may as well use them as the tools they were designed to be. It’s also no use just filling them out for the sake of it, the assessment has to be relevant for that patient and the results need to be acted upon. Of course there are times when a risk assessment isn’t appropriate, and that’s where you clearly document the rational for this.

 

References

Dougherty, L., Lister, S. and West-Oram, A. (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Chichester: Wiley-Blackwell.

Kondrup, J. et al. (2003) ‘ESPEN Guidelines for Nutrition Screening 2002’, Clinical Nutrition, 22(4), pp. 415–421. doi: 10.1016/S0261-5614(03)00098-0.

Malnutrition Advisory Group (2003) The “MUST” report: nutritional screening for adults. A multidisciplinary responsibility. Redditch, Worcestershire: MAG.

Volkert, D. et al. (2015) ‘ESPEN guidelines on nutrition in dementia’, Clinical Nutrition, 34(6), pp. 1052–1073. doi: 10.1016/j.clnu.2015.09.004.

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