Download Falls prevention - Southern Health NHS Foundation Trust

Guidance for completing RiO Falls Assessment
Forms
Question
Has the client had any falls in the past year
When did these falls usually occur
Where did these falls usually occur?
Details of last fall
Date of last fall?
Has the cause of your last fall been investigated
and have you received treatment for it?
Did you black out when you fell?
(unable to recall hitting the floor)
Where did the fall occur?
Did you feel dizzy before or during your fall? (but
did not black out)
Do you think you fell because of a problem with
your balance, strength or walking?
Do you take four or more types of medication?
Did your last fall cause a fracture?
Have you been given medication for bone
protection?
Do you have a problem with your eyesight?
Has it been treated by an optician?
Do you have pain or problems with your feet?
Details of events just before the fall
Can the client remember what happened?
What was the client doing?
Did the client experience any of these
symptoms:
 Fitting
 Chest pain
 Light – headedness
 Palpitations
 Blackout / faint
 Headache
 Visual Disturbance
 Legs giving way
SHFT Falls Prevention Team, July 2013
Guidance
Specify time of day
e.g. first thing in the morning, getting out of bed
Narrow down the place to where the person falls, e.g. in the
bedroom, bathroom
Have they seen GP / consultant?
If yes – refer to GP for assessment (unless GP was the one
referring patient ) to do cardiac/ neuro exam/ medication
review
Referral option – falls clinic via GP letter
What starts it, how long does it last?
Is it prompted by head/ neck movements / change in
positions?
Is hearing affected? check ears for wax, refer to GP
Refer to physio for balance or gait assessment.
Check walking aids
Offer advice dependent on own professional skills/ knowledge
Identify medications that may cause sedation or postural
hypotension
e.g. Bisphosphonates such as Alendronic Acid
plus calcium and vitamin D
Ask when they last had their eyes tested? Advise eye test if
more than a year since tested. Check if bifocals/varifocals
Give advice on risk of falls when wearing bifocals
Consider referral to Sensory Impairment team
Check if they can cut their toenails? Consider referral to
podiatrist or nail cutting clinics
Advise about suitable low –heeled supportive footwear
Consider if the person was using a walking aid, bending down
turning round
Had they taken their medication that day?
Had they eaten and drunk adequately?
What was the weather like?
Were they wearing shoes?
Any infections? UTI / Chest infections?
Is the person epileptic? Are they taking their medication?
Refer to GP if chest pain or black out /faints
Check lying and standing BP
Check pulse, record rate and rhythm
Had they eaten, drunk well
 Other
Was anyone else present at the time?
Observed signs and symptoms from above list
How many times has the client almost fallen in
the last year?
Is the client frightened of falling?
Afraid of injury
Not being able to get up
Not being able to get help
If the answer to the above question was yes,
please select reasons
Is there any evidence of environmental
Hazards?
Medication Review
Does the client take 4 or more different types of
medicines per day? (including those brought
over the counter and herbal remedies)
Has there been a recent change in medication?
Does the client have any problems getting or
taking their medication?
Does the client experience or suffer from any of
the following? Dizziness, depression, confusion,
memory loss, pain, diabetes, osteoporosis, heart
conditions, neurological conditions
If Osteoporosis selected please tick risk factors
Family history of hip fracture
Early Menopause (before 45 years old)
Hysterectomy (untreated with HRT)
Lack of exercise / immobility
Smoking and high alcohol intake
Lack of vitamin D
Planned or current long term steroid use
Gastrointestinal conditions, e.g. Crohn’s, Coeliac
Hypothyroidism
Liver disease
Rheumatoid Arthritis
Low body weight
History of fragility fracture (fall from standing
height)
Conclusion
Record in comment boxes
Record in the comment boxes
Action Plan
Name & Signature
SHFT Falls Prevention Team, July 2013
Advice as above
Did they have any near falls?
What time of day is it?
Consider using FESI as an outcome measure
Refer OT / PT for fear of falling
Consider referral for lifeline / call system
Has the HOMEFAST Tool been completed?
Does a referral to Occupational Therapist need to be made?
Discuss ways of reducing risks of falls
Consider homecheck / handyman services for small repairs
and safety checks
4 or more medications is termed polypharmacy. It increases
risk of falls. Are any of them culprit drugs e.g. sedatives,
antidepressants
(refer to medicines handout)
Has medication been reviewed in last 6 months
This could include not taking prescribed medication
Consider medication compliance. Are they able to swallow?
Do they need a Nomad?
Is the pain well controlled, what analgesia do they take?
Is there a diagnosis of dementia / Alzheimer’s?
If diabetic, do they check their blood sugars?
Do they see practice nurse for diabetic review?
If not already on medication for bones, refer to GP
If on bone medication check taking correctly
e.g. Alendronic acid, should be taken on an empty stomach
with a glass of water and the person needs to sit upright for
half an hour following
If low body weight, check body weight (BMI) and medical
conditions
Provide literature on bone health
Ensure aware of National Osteoporosis Society
Verbal advice given to client / carer
Written advice given to client / carer
Staying Steady leaflet from Age UK.
‘Better Balance’ exercise leaflet
‘Are you worried about Osteoporosis’ NOS
‘Cosyfeet’ or ‘DB Shoes’ footwear
Pendant alarms
Include key points and what action is required e.g. referral to
OT, physiotherapy, podiatry
Text can be copied into progress notes/ care plan
Date & time
SHFT Falls Prevention Team, July 2013