< Previous18 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com vention skills bundle to ensure effective HAP prevention, so nurses should take the lead in strategizing the implementation of these care protocols. Infection prevention standards Hospitalization in acute care settings impacts patients’ immune response, so hospital staff must follow infection prevention measures to lower the risk of developing HAIs, including HAP. Hand hygiene is an effective measure to prevent HAI and frequently is the focus of staff education. Studies show that access to bedside antiseptic hand scrubs contributes to an increase in hand hygiene adherence, which can lead to an overall reduction in HAIs. In addition, face masks can be effective at reducing transmission of airborne path o - gens such as those that cause pneumonia and influenza. Also, healthcare worker influenza vaccination is key to preventing HAP; antiviral prophylaxis should be provided to patients during a flu outbreak. Head of bed elevation Elevating the head of the bed is a simple in- tervention that may reduce aspiration risk. Raising the head of the bed to at least 30 de- grees as a deterrent to microaspiration in pa- tients on a ventilator has been well document- ed; some research suggests that 45 degrees is ideal for these patients. However, aspiration not associated with a ventilator is common in acute care patients, making aspiration risk as- sessment vital to safe nursing practice. If the assessment reveals that a patient is at risk for aspiration, elevating the head of the bed should be included in an HAP nursing inter- vention bundle. For patients with an altered mental status, including those with lethargy or sedation, the head of the bed should be elevated to at least 30 degrees when they are at rest. If tolerated, increasing the head of the bed to high Fowler’s position during mealtimes and when administering medications can help prevent aspiration. When caring for patients with a nasogastric tube for feeding, nurses should follow the ev- idence-based practice of ensuring that an x-ray has verified tip placement before feeding and maintain the head of the bed at more than 30 degrees at all times. Nurses also should docu- ment a thorough abdominal assessment, in- cluding measuring residual feeding, and talk to the healthcare provider about using a proki- netic agent such as metoclopramide, which has been shown to help reduce aspiration in patients with a feeding tube. Oral care HAP is most commonly caused by gram-neg- ative bacilli and Staphylococcus aureus that may flourish in the oral cavity of patients in acute care settings. Research has shown that standardized oral care reduces bacteria in the mouth, and several studies have reported a significant decrease in HAP with an effective twice-daily oral brushing program. (See Oral care tips.) Most nursing schools teach oral care, but providing it and helping patients perform it is reported to be very low. Evidence also sug- gests that oral care is poorly documented by nursing staff, which may indicate that staff ed- ucation is needed to improve adherence and documentation. Linking oral care to nursing assessment and educating staff on this best practice for preventing pneumonia may im- prove patient outcomes and reduce HAP in acute care settings. Studies also have shown that HAP preven- tion in surgical patients should begin with oral care before intubation. This nursing in- tervention may reduce microbial growth in the oral airway postoperatively when done in Research supports providing staff with a specific oral care protocol for patients to reduce the incidence of hospital-acquired pneumonia. Nurses should: • use a soft-bristle toothbrush or an electric suction toothbrush if the patient can’t brush his or her own teeth • use toothpaste that contains sodium bicarbonate • thoroughly examine the oral cavity, including the teeth and gingiva; for patients receiving antibiotics, watch for oropharyngeal candidiasis • ensure that patients’ dentures are cleaned after each meal and be- fore bedtime • use a mouthwash without alcohol to complete oral care. Oral care tipsMyAmericanNurse.com February 2020 American Nurse Journal 19 conjunction with other bundle interventions. Educating staff on this practice and adding specific oral care guidelines to the preopera- tive checklist may help reduce this postop complication. Increased mobility Early and intensive mobility interventions re- duce the incidence of HAP and the effects of deconditioning that accompany prolonged bed rest. Elderly patients and those with chronic diseases are at high risk for functional decline in as little as 72 hours if they’re on un- necessary bed or chair confinement. Unfortu- nately, although evidence supports early mo- bilization to reduce HAP, most patients still spend more than 60% of their time in bed. Bar- riers to early mobility include lack of time, concerns about patient safety, patients’ physi- ologic instability, lack of appropriate equip- ment to safely transfer patients, and insuffi- cient personnel to assist with ambulating. Nurses can take an active role in assessing safe patient transfers and ambulation to reduce fall risk. For example, they can complete the Banner Mobility Assessment Tool (BMAT) to assess basic balance and mobility. The BMAT is a valid and reliable tool for nurses to use at the bedside to determine patient mobility and the appropriate safety equipment needed to assist in transfers and early ambulation. After patient safety is established, inter- ventions such as getting the patient out of bed at least three times a day has been shown to significantly reduce the incidence of HAP. Adequate pain control is necessary to achieve patient mobility goals. Having an individualized schedule of analgesics and avoiding oversedation before getting out of bed may help patients meet mobility goals. Nurses should partner with physical therapy to develop safe interventions, such as super- vised walking programs, to reduce the effects of prolonged bed rest. Coughing, deep breathing, and incentive spirometry Coughing, deep breathing, and incentive spirometry have long been essential compo- nents in preventing NVHAP in postoperative patients. Because more than half of NVHAP patients are on a medical unit, adding these nursing interventions for nonsurgical patients as well is helpful. Coughing and deep breathing improve the expectoration of secretions and increase chest wall expansion to help reduce NVHAP. And some evidence suggests that controlled inspi- ration using incentive spirometry can improve oxygenation and reduce pulmonary complica- tions. However, no clear guidelines exist for the routine use of incentive spirometry in pre- venting NVHAP. The incentive spirometer may act as a phys- ical reminder to patients that coughing and deep breathing are important to prevent pul- monary infections. But protocols for the use of incentive spirometers vary widely among nurs- es and respiratory therapists, leading to reports of patient confusion. Therefore, a combination of the interventions discussed (patient educa- tion, elevation of the head of bed, early ambu- lation, oral care, coughing and deep breathing, and incentive spirometry) ap- pears to be the best way to prevent NVHAP. Resources, education, and collaboration Many of the interventions to prevent HAP are part of basic evidence-based nursing practice. Because of this, nurs- es can take the lead in developing and implementing prevention strategies within their scope of practice and mon- itor outcomes. Nurse leaders should provide the appropri- ate resources—equipment and personnel—so staff can achieve HAP reduction outcomes. Resources may include proper oral care equipment (such as electric suction tooth- brushes, mouthwash, dental floss, and den- ture care items) and safe and effective mobil- ity tools (such as gait belts, slide sheets, and proper lifting equipment). In addition, nurses must be properly educated in the use of any new or unfamiliar equipment so they feel con- fident about its use and are more likely to use it. Designating team champions on acute care units to assist in achieving HAP prevention goals also may help encourage staff interven- tion adherence. Healthcare organizations should provide education workshops to promote the use of fundamental interventions to reduce HAP. In- cluding patients and family in the education process and the plan of care upon admission also may help improve outcomes. A multidisciplinary team approach to prevention is the most effective strategy in reducing VAPs.20 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com According to Klompas and colleagues, a multidisciplinary team approach to preven- tion is the most effective strategy in reducing VAP; the same is true for NVHAP. This ap- proach includes a comprehensive team of physicians; nurses; physical, speech, and res- piratory therapists; nutritionists; and pharma- cologists. Bedside nurses are in an excellent position to take the lead in initiating this type of team collaboration and communicating with the interprofessional healthcare team on the most effective HAP prevention protocols. (See Interprofessional collaboration.) Nursing’s focus HAP is an underreported and understudied complication of hospitalization with signifi- cant patient morbidity and mortality. It’s re- sponsible for increases in hospital costs, lengths of stay, and discharges to long-term care facilities. Several fundamental nursing interventions have been associated with decreasing HAP risk; however, no standardized protocols exist for effectively monitoring and documenting them. A fundamental skills bundle that in- cludes best practices for infection prevention, oral care, early mobility, elevation of the head of the bed, and coughing and deep breathing may help improve outcomes, especially for high-risk patients. Staff education about these protocols may increase buy-in at the unit lev- el. Nursing’s focus should be on educating staff and ongoing research for these preven- tive strategies while also working with pa- tients, families, and an interprofessional team of healthcare providers, and to emphasize the interventions’ importance. AN The authors work at West Chester University in West Chester, Penn- sylvania. Carolyn D. Meehan is an associate professor of nursing and prelicensure program coordinator. Catherine McKenna is a clin- ical skills lab coordinator. References Boynton T, Kelly L, Perez A, Miller M, An Y, Trudgen C. Banner mobility assessment tool for nurses: Instrument validation. Am J Safe Patient Handl Mov. 2014;4(3):86-92. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the In- fectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61-111. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(8):915-36. Nakashima T, Maeda K, Tahira K, et al. Silent aspiration predicts mortality in older adults with aspiration pneu- monia admitted to acute hospitals. Geriatr Gerontol Int. 2018;18(6):828-32. Quinn B, Baker DL. Comprehensive oral care helps pre- vent hospital-acquired nonventilator pneumonia. Am Nurse Today. 2015;10(3):18-23. Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014; 46(1):11-9. Sopena N, Heras E, Casas I, et al. Risk factors for hospi- tal-acquired pneumonia outside the intensive care unit: A case-control study. Am J Infect Control. 2014;42(1):38-42. Tesoro M, Peyser DJ, Villarente F. A retrospective study of non-ventilator-associated hospital acquired pneumo- nia incidence and missed opportunities for nursing care. J Nurs Adm. 2018;48(5):285-91. As part of hospital-acquired pneumonia (HAP) prevention, nurses should initially focus on the principles of infection prevention and mon- itor each element of the fundamental skills bundle (head of bed eleva- tion, oral hygiene, patient mobility, and coughing and deep breathing) to reduce HAP risk. Then they should collaborate with the interprofes- sional team as needed to ensure the best outcomes. For example: • When risk factors for aspiration are identified, nurses should initiate a consult with speech therapy to determine additional prevention strategies, such as a swallowing screen for early diagnosis of poten- tial aspiration. • For elderly patients, nurses should discuss treatment options with the primary care provider and pharmacist to avoid polypharmacy, which may contribute to aspiration. • If pain is limiting patient mobility, nurses should consult with the pain management team to find therapies that will offer relief with- out detrimental side effects. • For patients at nutritional risk (such as those with a body mass in- dex less than 18 or a prealbumin below 16 mg/dL), nurses should collaborate with nutritional support services to provide supple- ments as indicated. Interprofessional collaborationMyAmericanNurse.com February 2020 American Nurse Journal 21 Please mark the correct answer online. 1. Which patient is at highest risk for as- piration that could lead to hospital-acquired pneumonia (HAP)? a. A man with a compound fracture of the tibia b. A 32-year-old woman who had an ap- pendectomy c. A woman who had an acute myocar- dial infarction d. A 76-year-old man with Parkinson’s dis- ease 2. Which statement about aspiration risk is correct? a. Healthy patients are not at risk for aspi- ration. b. GI conditions with mild nausea fre- quently result in aspiration. c. Esophageal blockages due to tumor or radiation treatment can put patients at risk for aspiration. d. Pneumonia caused by aspiration is an uncommon cause of death in patients who have had a stroke. 3. Which class of drugs is most likely to put patients at risk for aspiration? a. Proton pump inhibitors b. Antiarrhythmics c. Analgesics d. Beta blockers 4. The head of the bed of a patient with lethargy who is at risk for aspiration should be elevated to at least a. 10 degrees. b. 15 degrees. c. 20 degrees. d. 30 degrees. 5. To prevent aspiration and subsequent HAP in patients receiving enteral feedings via a nasogastric tube, nurses should a. be sure tip placement is confirmed by auscultation before the initial feeding. b. measure residual feedings and docu- ment abdominal assessments. c. elevate the head of the patient’s bed 90 degrees. d. avoid administering prokinetic agents such as metoclopramide. 6. Which of the following should be part of an oral care protocol for preventing HAP? a. Use a mouthwash without alcohol to complete the care. b. Use a mouthwash with alcohol to com- plete the care. c. Use a toothpaste without sodium bi- carbonate. d. Use a toothpaste with potassium bicar- bonate. 7. Which statement about mobility and reduction of HAP is correct? a. Patients should be kept in bed during the first 72 hours of hospitalization to avoid the risk of falls. b. Elderly patients are at high risk for func- tional decline in as little as 96 hours if not active. c. Nurses can use the Banner Mobility As- sessment Tool (BMAT) to assess basic balance and mobility. d. Most patients in the hospital spend more than 80% of their stay in bed. 8. All of the following statements about incentive spirometry are correct except a. Incentive spirometry may reduce pul- monary complications. b. Protocols for the use of incentive spirometers vary widely among nurses and respiratory therapists. c. Incentive spirometry may improve oxy- genation. d. There are clear guidelines for incentive spirometry for preventing nonventila- tor HAP. 9. Which statement about the role of in- terprofessional collaboration in preventing HAP is correct? a. The team should include only physi- cians; nurses; and physical, speech, and respiratory therapists. b. The team should include only physi- cians, nurses, nutritionists, and pharma- cists. c. When risk factors for aspiration are identified, nurses should initiate a con- sult with speech therapy. d. Nurses should work with physical ther- apy to keep a patient with pain in bed until he or she is pain free. 10. Patients with poor nutrition, which places them at risk for HAP, include those with a. a body mass index less than 48. b. a body mass index less than 18. c. a prealbumin higher than 18 mg/dL. d. a prealbumin higher than 25 mg/dL. POST-TEST • Preventing hospital-acquired pneumonia Provider accreditation The American Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Provider Number 0023. Contact hours: 1.36 ANA is approved by the California Board of Registered Nursing, Provider Number CEP17219. Post-test passing score is 80%. Expiration: 2/1/23 ANA Center for Continuing Education and Professional Devel- opment’s accredited provider status refers only to CNE activities and does not imply that there is real or implied endorsement of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the activity. The author and planners of this CNE activity have disclosed no rele- vant financial relationships with any commercial companies pertaining to this CNE. See the banner at the top of this page to learn how to earn CNE credit. CNE: 1.36 contact hours CNE22 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com J OHN A NDERSON * is a 72-year-old patient with colorectal cancer, hypoalbuminemia (an indi- cation of poor nutrition), and type 2 diabetes who was admitted to the medical-surgical unit after an open colon resection 4 days ago. His nasogastric tube was removed 2 hours ago. When you respond to Mr. Anderson’s call light, you observe that he’s distressed and that his hands are clasped over his abdomen. He states that “something gave way” while cough- ing and that he’s experiencing significant ab- dominal pain. Your assessment reveals that Mr. Anderson’s abdominal surgical incision has par- tially separated down to the fascia, with only a few of the staples still intact. You see a large amount of serosanguineous exudate in and around the wound, but no signs of redness, swelling, warmth, or foul odor. Although no evisceration has occurred, you recognize Mr. Anderson’s wound dehiscence as a rare but severe complication of abdominal surgery and immediately request the unit sec- retary to contact the patient’s surgeon. You re- assure Mr. Anderson that the surgeon will be in to see him soon. On the scene To decrease intra-abdominal pressure and stress on the wound, you place Mr. Anderson supine in the low Fowler’s position with his knees slightly bent and cover the wound with a saline- moistened, sterile gauze dressing. His vital signs are normal except for a heart rate of 102 beats per minute. Mr. Anderson rates his pain at 8 out of 10. His I.V. line is patent. To help control the patient’s pain, you administer his as-needed I.V. opioid and withhold all oral intake in case the surgeon recommends surgery. When the surgeon arrives, he orders an ab- dominal binder to help prevent evisceration. After discussing treatment options with the pa- tient, the surgeon orders negative pressure wound therapy (NPWT) due to Mr. Anderson’s chronic health conditions and increased risk of dehiscence recurrence. NPWT will provide secondary closure and enhance healing by pulling exudate and bacteria from the site while keeping the wound bed moist. Outcome Mr. Anderson requires a longer hospital stay to ensure that wound granulation occurs with NPWT and to manage his pain. Wound heal- ing through secondary intention increases his risk for further complications, such as infection or incisional herniation. After 7 days, Mr. An- derson is discharged with home health for continued wound care. Education To prevent dehiscence, teach patients to splint the surgical site when coughing, vomiting, or sneezing. An abdominal binder for those at risk for dehiscence may be helpful, but evidence supporting its use is still needed. Heavy lifting (10 lbs or more) should be avoided for 6 to 8 weeks after surgery. Additional teaching topics to enhance wound healing include incisional care, blood glucose control, increased dietary protein, and the use of stool softeners to pre- vent straining caused by constipation. Although dehiscence occurs in less than 3% of abdominal surgeries, it’s associated with a mortality of 14% to 50%, with evisceration in- creasing the risk of death. Conditions that increase intra-abdominal pressure (obesity) or may disrupt skin health (poor nutrition, steroid use, diabetes) place patients at in- creased risk of dehiscence. After surgery, clo- sure disruption from increased pressure due to an ileus, distention, coughing, broken su- tures, or infection also increases patients’ risk. Inspect the skin for signs of impending dehis- cence, such as localized bruising, pain, lack of a healing ridge by postoperative days 5 to 9, and nausea/vomiting. Early detection could save your patient’s life. AN To view a list of references, visit myamericannurse.com/ ?p=63553. * Names are fictitious. Wendy R. Downey is an assistant professor at Radford University School of Nursing in Radford, Virginia. Wound dehiscence Detect and report warning signs to save lives. By Wendy R. Downey, DNP, MSEd, RN, CNE STRICTLY CLINICAL Rapid Response FREE DOWNLOAD! ANA's Principles for Nurse Staffing | THIRD EDITION This updated edi琀on iden琀fies the major elements needed to achieve op琀mal staffing. The Principles will guide nurses and key decision-makers in iden琀fying and developing processes and policies to improve nurse staffing at every level and in any se ng. Under 25 Pages Download and print ANA's Principles for Nurse Staffing infographic to learn about the 5 Principles for Nurse Staffing. BONUS DOWNLOAD! Principles for Nurse Staffing Infographic! Nurse staffing decisions are based on the number and needs of the pa琀ents, families, groups, communi琀es, and popula琀ons served. Principle #1 HEALTH CARE CONSUMER All nursing care delivery systems must provide the necessary resources to meet each health care consumer’s individual needs and the demands of the unit. Principle #4 PRACTICE ENVIRONMENT Organiza琀ons must have appropriate nurse staffing plans. All se ngs need well-developed staffing guidelines with measurable nurse-sensi琀ve outcomes. Principle #5 EVALUATION Nurse staffing is an asset to ever-evolving health care systems. Appropriate nurse staffing, with sufficient numbers of nurses, improves the health of the popula琀ons. Nurses at all levels within a health care system must have a substan琀ve and ac琀ve role in staffing decisions. Principles for Nurse Staffing Op琀mal care is achieved through individual ac琀ons and collabora琀on with other health care team members. Nurses are full partners in the delivery of safe, quality health care. Principle #2 INTERPROFESSIONAL TEAMS Organiza琀onal leaders must create a workplace environment that values nurses as cri琀cal members of the health care team. Principle #3 WORKPLACE CULTURE To download both your FREE eBook and infographic go to: h琀p://bit.ly/StaffingAd24 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com Strangulation: A silent but deadly form of intimate partner violence Awareness and assessment are keys to getting victims the help they need. By Jessica McCarthy, DNP, MHSA, MSN, APRN, FNP-BC, and Denise Stagg, PhD, MSN, CNEMyAmericanNurse.com February 2020 American Nurse Journal 25 A CCORDING to the Centers for Disease Con- trol and Prevention (CDC), between 2003 and 2014, 55.3% of female homicide victims in the United States were the result of intimate part- ner violence (IPV). The CDC also reports that nearly one in four adult women and approxi- mately one in seven adult men report having experienced severe physical violence, includ- ing strangulation, from an intimate partner in their lifetime. According to the 2015 National Intimate Partner and Sexual Violence Survey (NISVS), 21.4% of female respondents have experienced severe physical violence in their lifetime. Strangulation is a violent and sometimes deadly act. (See Strangulation facts.) Many people believe that strangulation leaves obvi- ous evidence, but visible signs may not occur for hours to days after the incident. Victims frequently don’t report strangulation because they’re afraid and they don’t think they’ll be believed if no physical evidence exists. Your interviewing techniques and assessment skills can help detect strangulation in patients and identify those at risk for strangulation. Risk factors According to Glass and colleagues, victims who previously experienced a nonfatal stran- gulation (NFS) are six times more likely to be victims of attempted homicide and seven times more likely to die by homicide than those who haven’t experienced NFS. After a victim experiences one episode of NFS, his or her chance of experiencing recurrent strangu- lation episodes increases. In addition, accord- ing to Messing and colleagues, victims of mul- tiple strangulations are at a greater risk for miscarriages associated with the abuse, loss of consciousness, IPV injuries, and homicide. Sexual assault increases the risk for stran- gulation. Based on research by Zilkens and colleagues, the risk of being strangled is ap- proximately five times higher for women who’ve been sexually assaulted by an intimate partner than those assaulted by a stranger. More than 33% of NFSs occur in women 30 to 39 years old who were sexually assaulted by an intimate partner. Women who experience IPV that involves strangulation are at high risk for death. Other factors associated with NFS during sexual assaults include denial of free- dom, verbal threats, assault occurring in the victim’s home, and use of blunt force. Signs and symptoms An NFS can range from mild and transitory to serious and life-threatening, and it may result in injuries such as carotid artery dissection, thrombosis, or embolism, as well as bruising or fracture of the larynx, hyoid bone, tracheal rings, or thyroid cartilage. Subjective data in- dicating possible strangulation include: •neck or throat pain •discomfort or difficulty swallowing or talking •vocal changes •shortness of breath •loss of consciousness •memory loss •dizziness •feeling faint •blurry vision •involuntary urination or defecation •tinnitus. You should suspect NFS if a victim of IPV exhibits neurologic symptoms such as seizures, stroke symptoms, concentration and recall dif- ficulties, or agitation. Physical signs that may indicate strangulation include: •linear abrasions •bruising on the upper neck, chin, or face •subconjunctival hemorrhage Strangulation is the compression of anatomic neck structures leading to a reduction of blood flow to or from the brain that results in injury or death. Using the average handshake at 80 to 100 pounds of pres- sure as comparison: • a victim’s jugular veins will occlude when a perpetrator applies only 4 pounds of pressure • occlusion of the carotid arteries occurs with 5 to 11 pounds of pres- sure • a perpetrator applying 33 pounds of pressure to the victim’s trachea will cause it to collapse. Strangulation signs and symptoms may not be visible during the initial victim assessment. According to Zilkens and colleagues, approxi- mately 50% of strangulation victims will have no visible injuries, and some survivors may not even recall the strangulation incident because of cerebral hypoxia during the assault. Strangulation facts26 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com •conjunctivae petechia •neck swelling •neck tenderness upon palpation. Forty percent of NFS victims will present to healthcare professionals with a neck injury, voice loss or vocal changes, and/or difficulty breathing. However, they may not exhibit signs or symptoms of strangulation until 24 to 36 hours after the incident. Laryngeal edema may take up to 36 hours to occur, delaying air- way obstruction and respiratory compromise. Screening Organizations should develop IPV and strangu- lation policies for screening/assessment, evalu- ation, documentation, and discharge planning to help nurses in early detection and treatment. If your organization doesn’t have such policies, advocate for and help implement them. Ask the right questions When assessing a victim of IPV, ask if any form of strangulation has occurred and use wording (such as squeezed neck, choked, and choked off) that ensures that he or she under- stands what you’re asking. Structure questions about strangulation according to methods that could be used, such as “Has anyone squeezed or pressed against your throat until you could- n’t breathe, or you passed out? Has anyone wrapped his or her arm around your neck from behind and pressed against your throat?” In addition, ask how many times the victim has been strangled and help him or her break down the frequency into the number of stran- gulations in each incident and the number of times he or she has been strangled by present and past partners. Inform victims who’ve been strangled in the past 24 to 48 hours that they may experience delayed responses, including airway compromise or neurologic injuries. And remember that skin tone variations (such as darker tones) can hinder your identification of physical signs of strangulation. The Danger Assessment-5 (DA-5) tool provides nurses with a quick assessment to determine an intimate partner violence (IPV) victim’s risk for homicide or severe injury. For more information, visit www.dangerassessment.org/DATools.aspx . Questions Recommended clinician act ions Assessing risk Answer yes or no for each of the following questions. ("Partner” refers to your spouse, partner, ex-spouse, ex- partner, or whoever is currently physically hurting you.) • Has the physical violence increased in frequency or over the past year? • Has your partner ever used a weapon against you or threatened you with a weapon? • Do you believe your partner is capable of killing you? • Does your partner ever try to choke you? • Is your partner violently and constantly jealous of you? 4-5 positive responses: Report to police and/or domestic violence advocacy program or national hotline (800-799-7233) based on pa- tient’s choice; do the reporting with the patient. 3 positive responses: Complete full DA (download at www.danger assessment.org/DATools.aspx) or refer to someone certified in DA administration and proceed based on results. 2 positive responses: Explain that a 2 of 5 is highly predictive for se- rious assault/homicide, strongly recommend further immediate ad- vocacy, assist patients with phone calls. 0-1 positive response: Proceed with normal referral/process for IPV. Source: Adapted from Campbell, 2009, 2019; Messing et al. 2017MyAmericanNurse.com February 2020 American Nurse Journal 27 Use a screening tool Currently, no standard test, tool, or indicator exists to evaluate specifically for strangulation, and no national or international organizations have recommended one tool over another. However, one tool frequently discussed in the literature is the Danger Assessment (DA) tool, which is designed to detect the risk of deadly violence and extreme danger in an abusive in- timate relationship. Research indicates that the DA tool has the highest Cronbach alpha ( α =.66) compared to other lethality assess- ment tools. It’s available in a short version that includes only five questions (DA-5) to aid in identifying individuals at high risk for homi- cide or severe injury by an intimate partner. (See Assessing risk.) The full version can be administered if the results of the DA-5 raise concerns. The full DA tool includes use of a calendar that allows victims to record the types of IPV injuries they’ve experienced and their fre- quency. The calendar raises the victim’s awareness of the abuse and decreases his or her denial of it. The second part of the tool in- cludes 20 items requiring yes or no responses. The DA is scored by adding the number of “yes” items; the more “yes” answers, the greater the risk of severe repeated or lethal vi- olence. The full DA tool also is available ias an app (which includes the weighted scoring algorithm), available at myplanapp.org. The DA website also includes additional re- sources to help nurses and other healthcare professionals increase their knowledge of strangulation and assessment skills, and it also offers certification. Once certified, no re- newals are required. Training and certification are valuable and affordable but not necessary. However, healthcare professionals in settings such as emergency departments that frequent- ly encounter IPV victims may want to consider certification. At a minimum, healthcare pro - viders should incorporate the DA-5 for pa- tients who’ve been involved in a suspected or revealed IPV incident. (See Resources.) Nursing implications Understanding the prevalence of strangula- tion, its varying degrees of severity, and de- layed symptom onset can help you identify this form of IPV even when no obvious signs are evident during patient assessment. If you suspect IPV has occurred, take an unhurried approach to continuing the assessment and build trust with the patient as you ask relevant questions about abuse and injuries. Empha- size that strangulation symptoms may be de- layed and that the patient should report late or worsening symptoms immediately. Review your organization’s current policies and procedures related to IPV in general and strangulation in specific so that you’re famil- iar with treatment and reporting processes. If your organization doesn’t have any relevant policies, work with leadership to develop and implement them. The International Associa- tion of Forensic Nurses has a model policy toolkit to help organizations develop policies ( bit.ly/2ryGEtM ), which should include a pro - cess for connecting victims with resources (such as social workers and community serv- ices) that can help them develop a safety plan for the future. With increased education and community partnerships, nurses are in a power position when it comes to identifying IPV and strangu- lation risk factors and decreasing adverse ef- fects. These partnerships can help combat this silent and deadly act of violence. AN To view a list of references, visit myamericannurse.com/ ?p=64294. The authors are assistant professors at the University of Louisiana at Lafayette College of Nursing and Allied Health Professions. Resources Access these resources for more information about intimate partner violence and strangulation. Danger Assessment Tool (www.dangerassessment.org/DATools.aspx) This free screening tool is available in a variety of languages, as well as a version for use with women who are immigrants. The site also offers free training and certification for healthcare professionals. Family Justice Center Alliance (888-511-3522; familyjusticecenter.org/about-us) This research center, clearinghouse, and national affiliation organiza- tion for family justice centers serves victims of domestic violence, sex- ual assault, human trafficking, elder abuse, and child abuse. International Association of Forensic Nurses (forensicnurses.org/page/STDocs) The association offers a Non-Fatal Strangulation Documentation Toolkit to help nurses develop policies for their organizations. Training Institute on Strangulation Prevention (strangulationtraininginstitute.com) This organization offers free strangulation prevention resources, train- ing, and certification for healthcare professionals.Next >