Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Domains for Post Fall Interview
Details of the fall:
• client’s description of the fall,
• the nurse’s perception,
• the position from which the fall occurred (found to be the most useful question), and
• associated symptoms.
 
Physical Examination:
• vital signs, includes checking for postural hypotension,
• presence of anticoagulation therapy,
• assessment of visual impairment, neck movement,
• cardiovascular assessment,
• musculoskeletal assessment, including ability to raise legs independently when in bed, level of assistance to get up off floor,
• assessment for leg weakness, foot problems, and proper shoe fit,
• neurological assessment, assessment of sensory loss, focal deficits, and sitting and standing balance.
 
Behaviour:
• notation of behaviour, wandering,
• locomotion and transfer ability, and
• restraint use.
 
Environment Context:
• location,
• footwear,
• floor surface type, and
• equipment.