Care Home Falls Checklist On Warfarin
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Yes No Comments 1 Has the individual fallen > 1metre or > 5 stairs? 2 Is the individual showing any signs of a Stroke - facial droop or limb weakness? 3 Is there any evidence of intoxication? 4 Is the individual acting out of their normal self? 5 Has the individual been fully alert and conscious throughout with no loss of consciousness? 6 Is the individual dizzy or sweaty? 7 Has the individual suffered any amnesia or confusion post or prior to the event - that is not normal for them? 8 Has the individual vomited since the fall? 9 Has the individual’s colour changed in their face, limbs or centrally? 10 The individual has loss of circulation or nerve function to limbs 11 Has the individual got any evidence of swelling, deformity or body tenderness? 12 Is there any history of blunt or penetrating trauma to the chest or abdomen 13 Is there any break in the continuity of the skin - excluding minor abrasions? If ANY answers to the above questions are YES then you should call 999 without delay. If all answers to the above questions are NO, then the individual may be aided from the floor to a chair or bed. If the individual is normally mobile then after a few minutes they will need to attempt to weight bear - then continue 14 Is the individual able to weight bear as normal with no evidence of reduced mobility or pain anywhere that is not normal for them since the fall? (with or without mobility aids) 15 Does the individual have shortness of breath? 16 Does the individual have chest pain? 17 Is the individual very hot or cold to touch? 18 Was the individual dizzy before the fall? 19 Does the individual have a head injury associated with: If ANY answers to the above questions are YES then you should call 999 without delay If all answers to the questions are NO, then the individual should be encouraged to rest but continue as normal, while being monitored for 24 hours for any changes. Any Concerns call the GP, 111 or 999 at any time. • Loss Of Consciousness • Vomiting • Confusion • Memory loss • Dizziness • Blurred vision • On Warfarin Care Home Falls Checklist • Mobility • Acting normal self • Any pain • Acute vomiting • Acute confusion • Acute memory loss • Well-being • Confidence Things to monitor post falls: This falls checklist is a guideline used by the East of England Ambulance service and is used as a recommendation on how to best respond to a fall. The checklist is an easy to follow guide to ensure you have done everything possible, in the correct order, to make the best decision how to respond to the fall. Use the post monitoring checklist to ensure that ongoing care is happening, and that no signs of complications/deterioration are missed. This will ensure that you as a provider are giving the correct level of support for the individual following a fall.
Transcript of Care Home Falls Checklist On Warfarin
Yes No Comments
1 Has the individual fallen > 1metre or > 5 stairs?
2 Is the individual showing any signs of a Stroke - facial droop or limb weakness?
3 Is there any evidence of intoxication?
4 Is the individual acting out of their normal self?
5 Has the individual been fully alert and conscious throughout with no loss of consciousness?
6 Is the individual dizzy or sweaty?
7 Has the individual suffered any amnesia or confusion post or prior to the event - that is not normal for them?
8 Has the individual vomited since the fall?
9 Has the individual’s colour changed in their face, limbs or centrally?
10 The individual has loss of circulation or nerve function to limbs
11 Has the individual got any evidence of swelling, deformity or body tenderness?
12 Is there any history of blunt or penetrating trauma to the chest or abdomen
13 Is there any break in the continuity of the skin - excluding minor abrasions?
If ANY answers to the above questions are YES then you should call 999 without delay.
If all answers to the above questions are NO, then the individual may be aided from the floor to a chair or bed.If the individual is normally mobile then after a few minutes they will need to attempt to weight bear - then continue
14 Is the individual able to weight bear as normal with no evidence of reduced mobility or pain anywhere that is not normal for them since the fall? (with or without mobility aids)
15 Does the individual have shortness of breath?
16 Does the individual have chest pain?
17 Is the individual very hot or cold to touch?
18 Was the individual dizzy before the fall?
19Does the individual have a head injury associated with:
If ANY answers to the above questions are YES then you should call 999 without delay
If all answers to the questions are NO, then the individual should be encouraged to rest but continue as normal, while being monitored for 24 hours for any changes. Any Concerns call the GP, 111 or 999 at any time.
• Loss Of Consciousness• Vomiting
• Confusion• Memory loss
• Dizziness• Blurred vision
• On Warfarin
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• Acting normal self• Any pain• Acute vomiting
• Acute confusion• Acute memory loss• Well-being• Confidence
Things to monitor post falls: This falls checklist is a guideline used by the East of England Ambulance service and is used as a recommendation on how to best respond to a fall. The checklist is an easy to follow guide to ensure you have done everything possible, in the correct order, to make the best decision how to respond to the fall.
Use the post monitoring checklist to ensure that ongoing care is happening, and that no signs of complications/deterioration are missed. This will ensure that you as a provider are giving the correct level of support for the individual following a fall.
An individual has fallen or has been found on the floor
Assess individual’s responsiveness and for any injury (including cuts, bruising, deformities or pain)
No obvious injury sustained Obvious injury sustained
• Check for any pain, swelling or abnormality
• Check for understanding and comprehension
• If any doubt follow procedure for obvious injury
Once established as far as reasonably practicable that there has been no obvious injury sustained.
The correct moving and handling practice should be followed to assist the resident from the floor.
If the person is independent:Verbally talk through rising from the floor
If the person is dependent:The appropriate hoist / floor lifting cushion must be used to lift the person from the floor
It is safe to move the person.
It is not safe to move the person
Call ambulance / GP / NHS / 111
Notify the next of kin as agreed, commence falls investigation
• Do not move the person (unless in immediate danger of further injury).
• Call for assistance / alert senior staff
• Keep person warm and note any changes
• Assess level of injury, provide reassurance and take appropriate action (e.g. call ambulance / GP / NHS24)
• If competent take vital signs e.g. BP
• Attend to superficial wounds
• Injury to head suspected - ongoing observation for neurological changes
