Anticipation: Behavioral Risk Assessment

To be pro-active, nursing has enacted many risk assessments. They prove true on each and every patient who is seen. A couple of the current focuses are on preventing falls, preventing skin breakdown, as well as assessing and treating pain and the control of same. Can we say that regarding behavioral risks? Would it not be prudent that a behavioral risk assessment is completed on all patients regardless of why they are being treated? Nurses Announcements Archive Article

Anticipation: Behavioral Risk Assessment

What if part of every admission assessment, there was a system in place for behavioral risk assessments in patients? Much like skin, pain and fall, behavior could be assessed, a care plan created, and assessed per day/shift as your facility policy states.

Fall, skin and pain are all things that have proven the basic parts of every admission assessment. In doing so, with the accompanying care plans built into a plan of care, the goal is to reduce these risks. In an example of the Braden skin care assessment, even if the patient shows no particular risks, there is always at least a score of "1" which initiates a plan of care pertaining to same. Pain scale assessments are more subjective, but most are treated by the number that a patient scores their pain, and a plan is put into place. Same with fall risk. Even if a patient scores a "0" there is still an assessment that needs to be continually assessed--and in some facilities per shift. The same should be said regarding behavior risks.

There are many medical conditions which would result in a patient experiencing a change in mental status. And no two mental status changes are alike. If we are to be proactive, and keep nurses safe, would it not be prudent to have each and every patient undergo a behavioral risk assessment as part of their admission?

There is more than one thread on AN regarding nurses being assaulted by patients. And in any number of states, this is a crime. Would those numbers change if, in fact, a behavioral assessment was put into play, and there were clear interventions that could manage this?

I think that part of most every psych facility/unit there are rules regarding behaviors. There are medications and other interventions that are available. At any given time, escalating behaviors are nipped in the bud rather quickly and effectively.

The same can not be said about one's elderly patient who has a raging UTI and is just this close to septic. Or the patient whose stroke has left them with poor impulse control, aggressive behaviors that they have no control over, or any number of traumatic brain injuries that do much the same. Our demented patients. Even those patients who are terrified because they don't understand why they are acting the way that they are. And patient's reactions to anesthesia can not be discounted.

This can hold true in a pediatric population as well. It is often hard to distinguish between what is a normal pattern of behavior for a child, and what is an escalation to the point of being dangerous.

Our patients start out in such a way that they need help to function as they can not function themselves. It is not just physical manifestations that present. Co-morbidities could include undiagnosed mental illness. Behavioral components could include reaction to medications, disease process, infection.

If nurses have a voice in protecting themselves, it should start with assessment of the behavioral needs of a patient. Interventions that include a plan of care to prevent escalations. The team as a whole needs to decide that behavioral needs, as well as mental health needs, are just as forthcoming and important as pain, skin, and fall risk assessment.

Unfortunately, in any number of facilities, behaviors are reactionary in nature as opposed to proactive. Up to psychosis, patients can present as out of control due to any number of reasons. And it is not always under the patient's control. Safety is paramount. Would it not make sense to attempt to prevent these occurrences as opposed to attempts to control what is already out of control?

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jadelpn

About jadelpn, LPN, EMT-B

jadelpn, LPN, EMT-B

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I hope you will not take offense as I do not intend my comments in that way, but I am uncomfortable reading your article, because you mention the various risk assessments, such as skin assessment, pain, and fall assessments (all of which are conducted to keep the patient safe from harm), and then go on to mention that various medical conditions can cause an altered mental state, and then mention that if we are to be proactive and keep nurses safe, would it not be prudent to have every patient undergo a behavioral risk assessment on admission. I feel that when we are discussing issues such as behavioral assessments and interventions, that the discussion should take place from the point of view of what is in the patient's best interest, as nursing care is centered on the patient and their family. I am not saying that nurses safety is not very important (in my local ER a very large security guard is present), but I do not believe in what you are proposing in your article.

In reply to your first paragraph, I know that in our nearest ER ambulatory patients are asked behavioral risk questions i.e. suicide risk, at triage.

To my knowledge, more in depth behavioral assessments and interventions are performed on patients who present to the ER triage who are displaying certain types of behaviors, i.e., aggression, severe anxiety, depression, etc., with the intention of keeping the patient and other people free from harm. Having a trusted family member stay with a patient has shown, in many cases, to be very helpful. But, when it comes to using chemical or physical restraints, there are many risks involved for patients, and there are laws that must be followed closely when using these interventions, and patients have rights in regard to the use of these interventions.

Patients may be combative for many reasons i.e., stroke, head injury, medication toxicity, dementia, etc., and as nurses we are aware of certain medical conditions that can predispose to combativeness. I see higher medical priorities for the assessment and treatment for patients who, often with co-morbidities, have, for example, experienced an acute stroke, or patients who have experienced a head injury, or who are in an altered mental state with acute renal failure due to a kidney stone and medication toxicity, than a behavioral assessment on admission unless these patients are clearly presenting as a danger to themselves or others. That is not to say that a behavioral assessment or behavioral interventions will not be relevant/indicated at some point during the course of medical/nursing care, with the primary intention of keeping the patient free from harm.

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Well, I think it wouldn't be logical to asses a patient based on their behavior.

First, the reason why things such as skin and pain are criteria's to be considered is because they are physical assesesments. It is a biological factor that cannot be warped since almost all human body's work the same way, think of them as factories with the same tools. Behaviors, on the other hand, can be influenced by many things. That may not even lead to be a temporary behavior at the time of assessment. You would also have to know the history of why such behaviors arise on the patients, and that is why psychiatric fields exist, when a patient has some kind of psychological/behavior disorder, it is the focus of study and improvement for that patient.

Don't get me wrong, I do believe emotional and spiritual needs must be acknowledged during patient care. But, isn't the purpose of their stay in a hospital due to a condition affecting their body for a reason?

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Yes, skin is a physical assessment. However, fall risk is determined by some questioning that could be subjective based on pre set criteria. The same could be said for behavior risk assessment.

And I do think that we stop at a risk of suicide. But that is an extreme form of behavior risk, and perhaps the reason someone presents to an ED. But that in itself is not the only risk.

Not all behavior needs to be restrained. And by the presence of a "huge security guard" in hopes of prevention--well, what is the guard going to do if behavior is out of control? Restrain the patient?

The point to my article is that to assess risk before having to act on it could be a way to prevent nurses (and others) from being hurt.

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I'm not at all saying controlling a patient, or even less ignore, a patients mental well being. I think working with the patient and understanding why they might be acting that way might help you as a nurse have a wider sense of precaution.

Always being aware and alert of changes seen in patient, talking in a sense such as mood or behavior, might allow us to prevent injuries.

Understand that we have to work together and be in tune with one another, in order to have a better outcome.

Great topic tho!

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