Tag Archives: Nursing Assessment

Are there any valid instruments for assessing risk for violence in mental health patients and is use of these instruments associated with fewer incidents of assaults on staff by patients?

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Bottom line:  There is some limited evidence that use of risk assessment tools can predict violent behavior by patients and can be associated with  reduction in aggressive incidents.

A systematic review in JBI+ COnNECT (JBI Library of Systematic Reviews. 2009;7(6):175-223) identified one retrospective study (Kling, 2006) of a tool to assess inpatients for risk of violent behavior.  In PubMed this reference led to other studies, including an RCT (Abderhalden, 2008) and a pilot study (Fluttert 2011)

Kling, R., et al., Use of a violence risk assessment tool in an acute care hospital: effectiveness in identifying violent patients. AAOHN Journal, 2006. 54(11): p. 481-7. (Available in print at Health Sciences Center Library.)
Reviewed charts at 1 acute care hospital for 117 violent patients and 161 randomly selected, nonviolent patients admitted during the same period.  Compared findings of a risk assessment tool in these populations.  Tool had moderate senstivity (71%) and high specificity (94%).  Limitation – only 35% of the non-violent patients and 75% of the violent patients were evaluated using the tool.

Abderhalden C, et al. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008 Jul;193(1):44-50.
Cluster RCT randomized 14 psychiatric units to use of Swiss version of the Brøset Violence Checklist (BVC–CH) or usual care for patients admitted to these units.  RESULTS: Adjusted RR indicate 41% reduction in severe aggressive incidents and a 27% decrease in use of coercive measures.  There was no decrease in severity of aggressive incidents.

Fluttert FA, et al. The development of the Forensic Early Warning Signs of Aggression Inventory: preliminary findings toward a better management of inpatient aggression. Arch Psychiatr Nurs. 2011 Apr;25(2):129-37.
Describes development of a new risk assessment tool.

PubMed search:  “Inpatients/psychology”[mesh] AND “Violence/prevention and control”[mesh] AND assess*

Reviewed 4/18/14  AA

How do you ensure proper placement of the vented nasogastric tube?

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PubMed
Results include a recent systematic review, “Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital,”  that aims to define best practices for ensuring proper placement of tube in acute care hospital setting.
http://www.ncbi.nlm.nih.gov/pubmed?otool=emorylib&term=(”Intubation, Gastrointestinal/methods”[MAJR]) AND (suction OR decompression OR medical errors) AND English[lang] AND systematic[sb]
If you want to look at other literature besides systematic reviews, just removew the systematic[sb] from the PubMed search box.

CINAHL
Used search statement similar to PubMed search above.  Most of the relevant references were older, so that information should be covered in the systematic review noted in the PubMed search.  You can view results here.

Reviewed 4/14/14  AA

Does taking calf and thigh measurements weekly prevent complications from lower extremity DVTs in acute rehabilitation patients?

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JAMA 1998 Apr 8;279(14):1094.
This systematic review of clinical assessment and tests for diagnosing DVTs found that leg swelling (as with other symptoms and signs, see Table 2) occurred in patients with and without DVTs. Presence of 1 or more of these signs (pain, tenderness, edema, Homans sign, swelling or erythema) did not have good positive or negative likelihood ratios for diagnosing or ruling out DVT (see Table 3 for LRs from various studies. Now various clinical prediction rules have been developed that combine clinical assessment with test results.

Phys Ther 2004 Aug;84(8):729. This review suggests physical therapists should screen for DVT using such a clinical decision rule and refer any patients with 3 points or more to physician immediately for possible further testing. Points based on the following:
Add 1 point each for
1. active cancer
2. paralysis, paresis or recent plaster immobilization of lower extremities
3. recent episode of being bedridden after major surgery
4. localized tenderness
5. leg swelling
6. calf swelling > 3 cm compared with asymptomatic leg
7. pitting edema
8. collateral superficial veins
Subtract 2 points if alternative diagnosis as or more likely than DVT. Limitations:  This review focused on outpatients.

Reviewed 4/21/2014 ldt

What can happen if patients’ intake and output is not properly monitored after surgery?

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Bottom line: Monitoring and documenting intake and output after surgery is important for detecting conditions, such as postoperative urinary retention (POUR), which is associated with risk of overdistention and permanent detrusor muscle damage, leading to difficulties with urination.  Decreased output can also be an indicator of a urinary tract infection.

Summary:  Feliciano T, et al.  A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge.  J Perianesth Nursing.  2008; 23(6): 394-400.

Postoperative care.  In:  Lippincott’s Nursing Procedures and Skills.  Revised October 4, 2013.

Reviewed and updated 4/11/2014 ldt

In performing an integumentary assessment, how do definitions of intact and not intact skin apply to documenting intentional breaks in the skin (eg, surgical incisions)?

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Bottom line:  There is no clear documentation in the literature designating intentional breaks in the skin, due to incisions, chest tubes, etc., as specifically not intact skin.

Summary:

CDC Key Terms
http://www.cdc.gov/nhsn/PDFs/HSPmanual/7_HPS_keyTerms.pdf
Non-intact skin is defined as “areas of the skin that have been opened by cuts, abrasions, dermatitis, chapped skin, etc.”

Larson E, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart Lung. 1997 Sep-Oct;26(5):404-412.
This epidemiologic study of skin damage on nurses’ hands describes specifications for non-intact skin. Table II (p. 406) describes completely intact skin as that without abrasions or fissures.

Several nursing blogs include discussions of the ambiguity of how to document skin intactness for patients with surgical incisions.

Reviewed 4/25/2014 ldt

Communicating about evidence-based practice in patient care

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Welcome. This blog facilitates communication on issues of evidence-based practice by Emory Healthcare Nursing Quality Initiatives teams. Questions posed by the teams and information to address those questions will be documented in these posts.