Appendix B5: Falls Assessment Cue Sheet The Falls Management Program Manual MedicationsReview the resident's drugs in the MAR and PRN records. Consider all drugs in each of the classes listed below when completing the medications section of the Falls Assessment.AntipsychoticAntidepressantTrade namesGeneric namesTrade namesGeneric namesAbilifyClozarilEtrafonHaldolLoxitaneMellarilMobanNavaneOrapPermitilProlixinRisperdalSerentilSeroquelStelazineTaractanThorazineTindalTrilafonTriavilVesprinZyprexaGeodonaripiprazoleclozapineperphenazinehaloperidolloxapinethioridazinemolindonethiothixenepimozidefluphenazinefluphenazinerisperidonemesoridazinequetiapinetrifluoperazinechlorprothixenechlorpromazineacetophenazineperphenazineperhenazinetriflurpromazineolanzapineziprasidoneAnafranilAsendinAventyl, PamelorCelexaDesyrelEffexorElavilLexaproNardilNorpraminPaxilParnateProzacRemeronSerzoneSinequanSurmontilTofranilWellbutrinZoloftclomipramineamoxapinenortriptylinecitalopramtrazadonevenlafaxineamitriptylineescitalopramphenelzinedesipraminefluoxetinetranylcypromineparoxetinemirtazapinenefazodonedoxepintrimipramineimipraminebupropinsertralineBenzodiazepinesDigoxinTrade namesGeneric namesTrade namesGeneric namesAtivanCentraxDalmanDoralHalcionKlonopinLibriumPaxipamProSomRestorilSeraxTranxeneValiumXanaxlorazepamprazepamflurazepamquazepamtriazolamclonazepamchlordiazepoxidehalazepamestrazolamtemazepamoxazepamchlorazepatediazepamalprazolamDigoxinLanoxicapsLanoxinNovo-digoxindigoxinSedatives/hypnoticsTrade namesGeneric namesAmbienAtarax, vistrailBusparAquachloralEquanil, MiltownSeconalSonataVersedzolpidemhydroxyzinebusprionechloral hydratemeprobamatesecobarbitalzaleplonmidazolamOrthostatic HypotensionEquipment needed: stethoscope, sphygmomanometer, watch with a second hand.Take the resident's blood pressure in the right arm unless otherwise indicated and take an apical heart rate for 60 seconds. Encourage the resident not to smoke and to remain calm for at least 10 minutes before the test.For ambulatory residents, take BP readings in the sitting position and then 1 minute after standing. Ensure that the resident has been sitting for at least 5 minutes before taking the first measurement. Use staff assistance when necessary for resident safety.Subtract the values obtained while resident is standing from the values obtained while the resident was sitting. Determine if there is a reduction of ≥20 mm Hg in systolic pressure for postural hypotension.VisionObserve the resident during his/her activities of daily living and while he/she moves about in his/her room, bathroom, hallway, and dining room. Determine if the resident stumbles, trips, has difficulty finding objects or detecting changes in floor surfaces, or shows other signs of poor vision.MobilityComplete a Mobility and Transfer Assessment for all residents who ambulate or transfer without human assistance. Include residents who use a cane, walker, or wheelchair and those residents who should be assisted but get up unsafely without assistance.TestDescriptionGet Up and Go Test:Ask the resident to sit in a standard armchair, rise, walk 10 feet, turn, walk back to the chair, and sit down. The resident should wear his/her normal footwear and use his/her customary walking aid. Look for unsteadiness, difficulty rising or lowering, and any gait problems. Determine level of staff assistance required for safety.Transfer Test:Ask the resident to transfer in and out of the bed, on and off the toilet, and in and out of the lounge chair. Determine if the resident is safe; if the height of the bed, toilet, or lounge chair needs adjustment; if existing handrails need adjustment; and if the resident's assistive device needs further evaluation.Wheelchair Screen:For all residents who use a wheelchair or sit in a wheelchair for reasons other than transport only, collect the following measurements and assess the resident's position while seated. Based on your evaluation, determine if the resident is unsafe while seated in the wheelchair.[D] Select for Text Description.Unsafe BehaviorReview the chart and MAR, obtain a history from the family, and talk with staff about the resident's behavior. Complete the Unsafe Behavior Worksheet if necessary to determine the following:LocationTime of dayFrequencyPotential triggersResident's agendaMotivationPeople involvedUnsuccessful staff approachesNew interventions Current as of February 2010 Internet Citation: Appendix B5: Falls Assessment Cue Sheet: The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanapb3.html
Back
