RISK ASSESSMENT TOOL
The information published in this Guide is for general and educational purposes only. This Guide will not substitute any existing guidelines or is in no way meant to be a substitute. No action or inaction should be taken based solely on the information provided in this Guide. Our aim was to define a practical guidance for clinical practice to provide staff with some rationale addressing the individual patient requirements. Use this tool to factor an overall risk for a serious venous needle dislodgement.
Thank you for using the Risk Assessment Tool
Step 2
0 POINT VERY LOW OR LOW
* The patient understands the implications of
VND and is sufficiently alert to take action if a
VND, or a problem that could lead to VND, occurs
Or
* A device that raises an alarm when a VND occurs
1 POINT MEDIUM
* The patient sleeps during dialysis, especially if
they are hard to wake up.
Or
* The patient has impairments that could affect
their ability to notice VND (such as lowered skin
sensitivity or poor eyesight) or has
communication difficulties.
2 POINTS HIGH
* There is more than one risk factor or
any of the risk factors are particularly severe
(e.g. patients going into deep a sleep)
Step 1
0 POINT VERY LOW OR LOW
* The staff can observe the patient and easily access.
Or
* A device that raises an alarm when a VND occurs.
1 POINT MEDIUM
* There is a reduction in the number of staff able to make checks on the patients.
Or
* The staff are unable to access clearly due to the patient's location, covers, poor lightning etc.
2 POINTS HIGH
* There is more than one risk factor present
Step 3
0 POINT VERY LOW OR LOW
* There is no suggestion that the patient´s
actions during dialysis will lead to VND.
1 POINT MEDIUM
* The patient suffers side effects (e.g.
hypotension, cramps, itching) that could lead to
unpredictable movement.
Or
* The patient is restless, not fully aware of being
on dialysis or know to tamper with the tapes
needles and/or lines.
2 POINTS HIGH
* Patients with more than one risk factor.
Or
* Patients who have had more than one
unexplained needle dislodgement should
score 2.
Step 4
0 POINT VERY LOW OR LOW
* A standard taping protocol designed to
prevent VND is used.
1 POINT MEDIUM
* The taping technique does not include
measures to resist tugging on the needle tubing.
Or
* The taping has to be modified in a way that
makes it less secure (e.g. allergy, steep needle
angle etc).
2 POINTS HIGH
* Patients with more than one risk factor.
Final score
Your final score is:
SCORE 0 - 2 *Continue with secure taping and maintain awareness of VND * No further actions is needed unless there is a change in the patient´s condition or the management of the unit. |
SCORE 3 - 4 * Apply the EDTNA/ERCA recommendations to minimize the risks. * Ensure that taping technique is secure and consider adding a documented check of taping security after starting dialysis. * If a patient is not fully aware of the risk of VND, provide or reinforce education if possible. * Make it as easy as possible to observe the patient and their accessment. * If appropiate, increase the frequency that staff check the security of the needles. * If appropiate, consider using a protective device approved for detecting VND. |
SCORE 5 - 8 * Apply the EDTNA/ERCA recommendations to minimize the risks as described for medium risk. * Consider use of a protective device approved for detecting VND even if more frequent checks can be carried out. |
Summary
Description | Information | Points | |
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Discount : | |||
Total : |