FALLS - Nursing Assessment Guideline
If a resident falls, is lowered to the floor, or slides out of chair, lift into bed. The following assessment completed before deciding to observe or to call the provider on call. The only exception to lifting the resident into bed would be for an obvious neck injury.
1. Describe the incident, if witnessed, or the anatomical position of resident when found.
2. Describe pre-fall signs and/or symptoms: increased confusion, lightheadedness, chest pain, weakness, dyspnea, slurred speech, gait change or contributing environmental condition.
3. Describe post-fall signs and/or symptoms: reports of pain, weakness, dyspnea, slurred speech, observed seizure, inability to move or loss of consciousness.
4. Any recent changes: other incidents, change in status or medications. Is the resident on Coumadin? If YES what is the most recent INR?
5. What were the first vital signs and the current vital signs? (apical pulse, any new rhythm change)
6. Describe current level of consciousness and apparent or possible injury: laceration, position of limb, swelling, ecchymosis, response to range of motion, location and amount of pain.
A. After placing in safe and comfortable place and completing assessment, give prn analgesic, apply ice or pressure and contact the on-call provider as follows:
Emergency: For lacerations deep, long or irregular in shape, especially if bleeding is profuse and cannot be stopped with ice and pressure ·Facial wounds >1cm or wounds with foreign body present in wound ·Apparent fracture with angulation of extremity or obvious compound fracture ·Sudden loss of color, warmth or feeling in hand or foot of injured limb ·Loss of consciousness > 5 minutes ·Extreme blood pressure change lasting > 30 minutes
Routine: Incident without change in vital signs but with pain or dysfunction lasting > 1 hour
Notification: All others as dictated by nursing facility policy