CHECKLIST ACTION PLAN - Interior Health · longer replacement legs for the furniture, chair...

CHECKLIST & ACTION PLAN©

Name: _________________________

September 2012

PHONE NUMBERS OF PEOPLE AND SERVICES TO HELP

EMERGENCY: POLICE, FIRE, AMBULANCE

911

RELATIVE :

CLOSE FRIEND :

NEIGHBOUR #1 :

NEIGHBOUR #2 :

DOCTOR :

SPECIALIST :

PHARMACIST :

HOME AND COMMUNITY CARE OFFICE :

HEALTHLINK ( NURSE – 24 HOURS A DAY) :

TOLL FREE: 811

BC PHARMACIST LINE (5 – 9PM DAILY) :

TOLL FREE: 811

DIAL A DIETICIAN :

TOLL FREE: 811

PODIATRIST :

SENIORS RECREATION CENTER :

MEDICAL EQUIPMENT SUPPLIERS :

PUBLIC HAZARD REPORTING :

SERVICES TO HELP PHONE NUMBER

September 2012. Permission for use of this document is given to the BC Health Authorities or their contracted agencies. Use by all others requires written permission from Dr. Vicky Scott BC Injury Research and Prevention Unit: [email protected] 2

TABLE OF CONTENTS

Your Fall Prevention Action List ............................................................. 21

How to Get Up after a Fall ....................................................................... 22

Track Your Progress ................................................................................. 20

Outside of the Home .................................................................................. 19

Taking Charge of your Health ................................................................... 15

Stairs & Elevators ........................................................................................ 18

Instructions for completing the Checklist & Action Plan .................... 4

Bedroom ....................................................................................................... 5

Living Room & Sitting Area ..................................................................... 6

Bathroom ...................................................................................................... 7

Dining Area & Kitchen .............................................................................. 10

Lighting ......................................................................................................... 11

Clothing & Footwear .................................................................................. 12

Mobility and Equipment ............................................................................ 13


INSTRUCTIONS

How to use the SAIL Checklist and Action Plan:

• This Checklist and Action Plan is part of the Strategies and Actions for Independent Living (SAIL) fall prevention program for home support clients but may be used as an independent tool for home modification to reduce the risk of fall among older adults living at home.

• Work through the SAIL Checklist and Action Plan on your own or with help from your health care professional, or your family and friends. If you receive home support services, your community health worker (CHW) may be able to help.

• Think about potential problem areas and decide what you would like

to do to help stay healthy, independent and safe at home. Take this list with you as you walk about your home to answer the questions and consider actions. If you do not see easy solutions, talk with your health care professional for more ideas.1

• Put a mark in the appropriate box beside the “Ideas for Action”. If you mark “No” then put a “√” beside the actions you plan to take.

• You may have other ideas. Put these ideas down on your action list (p. 21).

• Record the date you finish an action on your action list (p. 21).

• Congratulations! You are taking action to stay healthy, independent and safe at home.

1 In B.C., the term “health care professional” used in the “ideas for action” sections of the Checklist and Action Plan refers to a physiotherapist, occupational therapist, physician, long term care case manager, home care nurse, home support supervisor or other health care provider that is a member of a College covered under the BC Health Professions Act.


BEDROOM

1. Can you get in and out of bed easily on your own? Yes Some of the time No, then:

Ideas for Action: • Do more activities that improve your strength and balance, such as the SAIL

Home Activity Program. • Get a bed assist rail and/or raise the bed, or replace your mattress. Ask your health care professional for suggestions that can work for you.

2. Do you have a phone beside your bed?

Yes No, then:

Ideas for Action: • Plug in phone next to your bed or keep a portable phone beside your bed. Note: Always wear your person alarm system (e.g., Lifeline) so you can call for help if needed.

3. Can you turn on a light easily before you get out of bed?

Yes Some of the time

No, then:

Ideas for Action: • Get a bedside lamp or ‘touch” light that you can reach easily. • Install a motion sensor nightlight that will turn on when you get out of bed. • Keep a lightweight flashlight with an easy to use on/off switch beside your

bed in case of power failure. Keep spare batteries nearby or use a windup flashlight.

Note: Allow time for your eyes to adjust to the change in light before moving.

4. Is your bedding always clear of the floor?

Yes Some of the time No, then:

Ideas for Action: • Use sheets, blankets or bedspreads that do not hang on the floor.

5. If you use a walking aid at home, can you reach it from your bed?


Ideas for Action: • Find a safe place for your walking aid that is still in easy reach from the bed,

or Hav• e someone available to bring your walking aid to you.



1. Can you get in/out of your favourite chair or sofa easily on your own? Yes Some of the time No, then:

Ideas for Action: • Do more activities that improve your strength and balance. Practice

standing up from your chair or sofa several times each day. • Raise the height of the chair or sofa (e.g., lengths of wood, blocks, buying

longer replacement legs for the furniture, chair platform). Make sure the setup is safe and stable.

• Inspect your chair so that it has a firm seat and solid armrests and that it fits your body size.

• Avoid swivel and rocking chairs that do not lock. Ask your health care professional for suggestions tha• t can work for you.

2. Are all cords, furniture and clutter kept away from walkways?

Yes

Some of the time No,

electrical cords with clips or tape along the outside of the

g and put coloured tape

(e.g., coffee

then:

Ideas for Action: • Fasten phone or

wall to keep them away from where you walk. • If you use portable oxygen, secure any extra tubin

on tubing that lies on the floor to increase visibility. • Remove or rearrange any items that you could trip on

table, end table, magazine rack, heater, waste basket).

3. Are the things you need often easy to reach (e.g., telephone, window openers, curtain cords, TV remote, light switches, wall sockets, etc)?


deas for Action: re or other items so you can easily reach what you need.

I• Rearrange furnitu• Attach cords or long handles to switches and openers that and are above

shoulder height.

LIVING ROOM &

SITTING AREA

BATHROOM

1. Can you move around in the bathroom easily without holding on to towel racks, taps, shower doors, or touching the walls?


Ideas for Action: • Ask your health care professional about grab bars, toilet frames, transfer

poles and other aids that can work for you. • Do more activities that improve your strength and balance.

2. Can you get in and out of the bathtub or shower easily on your own without holding on to towel rails or soap dishes?


Ideas for Action:

• Ask your health care professional about shower chairs, grab bars, and other suggestions that can work for you.

• Do more activities that improve your strength and balance.

3. Can you get on and off the toilet easily on your own?


Ideas for Action: • Ask your health care professional about toilet risers and other suggestions

that can work for you. • Do more activities that improve your strength and balance.



4. On the bottom of your tub or shower, do you have slip-resistant strips, a non-slip textured surface or a non-slip rubber mat?

Yes No, then:

Ideas for Action: • Install slip-resistant strips or apply a slip- resistant finish to the bottom of

your tub or shower or get a non-slip rubber mat. • If you use a non-slip rubber mat, make sure it is secure before stepping on

it and make sure both sides are cleaned, rinsed well and hung to dry after each use.

• Replace your non-slip rubber mat regularly before it starts to lose its grip.

5. Do the rugs or bath mats on your bathroom floor always stay secure when you step on them with one foot?

Yes No, then:

Ideas for Action:

• Use a bathmat with a non-skid backing. • Ask your health care professional about shower chairs; grab bars and other

suggestions that can work for you. • Do more activities that improve your strength and balance.

6. Can you easily reach your soap, shampoo and towel?

Yes No, then:

deas for Action: e, a soap/shampoo dispenser or shower/bath caddy to

b bar installed to hold on to while you reach for something if

I• Use soap on a rop

keep things within easy reach or have someone help you whenever you shower.

• Have a grathere is no other way to bring the item closer.

BATHROOM continued

Use of proper equipment or a mobility aid can decrease fall risk. Some equipment that may be helpful:

• hand rails along stairs and hallways

• stable, supportive chair with armrests

• grab bars in the shower or tub, and on the wall

• floor to ceiling pole • prescribed walker, cane, or wheelchair • bed assist rails to help with getting in and out of bed • toilet riser • bath chair, stool or bench • hand-held shower • permanent slip-resistant strips for shower, tub or floor • hip protector garments to prevent hip fractures



1. Can you easily get to your kitchen or dining room table? Can you sit down and stand up easily from your chair here?


Ideas for Action: • Avoid using a chair with wheels or that swivels. • Use a chair with a seat that is high enough and that can be moved without

strain. • Do more activities that improve your strength and balance. • If you eat with others, wait until there is a clear path before leaving the table.

If you use a walker, cane or wheelchair, make sure it is beside you before • leaving the table (Ask someone to bring it to you if needed). Take extra care.

• Ask your health care professional for more suggestions that can work for you.

2. Are spills cleaned up as soon as they happen? Yes Some of the time

No, then:

deas for Action: lean up the spill

• eantime, try to avoid that area of your h

I• Ask someone to c as soon as possible, or keep a

ome.

long-handled mop near the kitchen to wipe up small spills quickly. In the m

Note: Bending over to clean up spills can lead to a fall

3. Can you easily reach items you use frequently without having to bend low or reach high, or stand on a stool?


deas for Action: se frequently to a place that is easier for you to reach

helves that slide out. the items or do the whole job for you.

I• Move items you u

them. • Install s• Ask someone else to get you

DINING AREA & KITCHEN

LIGHTING

1. Do you have lights and lamps that are bright enough for you to see clearly?

Yes No, then:

Ideas for Action: • Install compact fluorescent bulbs (energy efficient) 18 to 27 watts or 75-

100 watt incandescent bulbs, unless the light manufacturer recommends otherwise.

• Don’t rush – allow time for the light to come on completely. • Halogen bulbs also give off good light, but can become hot.

2. Do all of your lights work?

Yes No, then:

Ideas for Action: • Get help to replace all burned out light bulbs. Have any broken light

fixtures repaired or replaced.


CLOTHING & FOOTWEAR

1. Do all your shoes and slippers fit comfortably and securely and do they have a non-slip bottom?

Yes No, then:

Ideas for Action: • Replace shoes and slippers that are too loose or too tight. • Avoid all flip-flops and open heeled slippers, shoes or sandals. • Wear shoes or slippers with a low heel and with a large contact area (area of

the sole in contact with the floor). • Wear shoes with adjustable straps or laces so they fit securely and can be

adjusted if your feet swell. Keep a long-handled shoe h• orn handy.

• Talk to your doctor if you have swollen feet. s that can work for you. • Ask your health care professional for suggestion

2. Do you always sit when getting dressed or putting on your shoes?


deas for Action: ir where you get dressed and where you put on shoes.

I• Place a sturdy cha

3. Do you wear clothes (including night wear, pants, skirts, dresses, dressing gowns/house coats) that fit well and have no dangling belts?


deas for Action:

lothing so it does not hang too low (tripping hazard).

e belt around each ng

I• Alter or replace c• Avoid walking on stairs in clothing that is loose and hangs low (e.g. long

housecoat or dressing gown, long skirts or dresses). • If the belt on your dressing gown is too long, wrap th

loop once or use some other technique to make sure the belt does not hatoo low, or shorten the belt.



1. Can you walk around your home without holding onto furniture or touching walls, or leaning on counters or tables?

Yes

Some of the time

No, then:

Ideas for Action: • Do more activities that improve your strength and balance. • Consider using a walker or a cane. • Consider installing hand rails along the wall. • Keep walking paths clear. • Ask your health care professional for suggestions that can work for you. • Ask about a referral to a physical or occupational therapist.

2. Can you walk inside or outside your home without becoming short

of breath or weak in the legs? Yes

Some of the time

No, then:

Ideas for Action: • Get a wheeled walker with locking brakes and a seat to sit on. • Tell your doctor if you become short of breath or weak in the legs. Tell your

doctor if this gets better or worse over time. • Do more activities that improve your strength, balance and endurance. • Ask your health care professional for suggestions that can work for you.

3. If you use a mobility aid like a walker or a cane, do you feel safe and steady using it?

Yes

Some of the time

No, then:

Ideas for Action: • Talk with your health care professional to learn about the appropriate size

and safe use of mobility aids. • Ask your health care professional for suggestions that can work for you.

MOBILITY & EQUIPMENT


4. Are your assistive aids in safe condition? (e.g. walker, cane “reacher”, bath equipment, toilet riser, wheelchair)

Yes No, then:

make sure the

th stool, toilet riser or cane ing order (brakes work, no

Ideas for Action: • Ask about a referral to a physical or occupational therapist to

assistive aid is the right one for you. • Check your assistive aids such as a walker, ba

re in good workregularly to make sure they acracks in the frame, rubber tips are not worn, etc.).

• Contact a local medical equipment dealer to have any broken or worn assistive aids repaired or replaced.

5. Do you avoid carrying large or bulky items? Yes Some of the time No, then:

Ask for help when carrying large or bulky items. a large basket or a grocery cart.

with a

hand while using the handrail

Ideas for Action: • • Use a walker with• If you must carry items up and down stairs, carry them in a bag

handle that goes over your shoulder so both hands are free. • Carry small items close to your body with one

with the other hand.

6. Do you have a personal alert system and use it when needed?

Yes N

personal alert system like Lifeline, and keep it with you at all times. Personal alerts are available as a pendant or a wristband. An automatic fall

available. People often have unnecessary injuries or more

o, then: Ideas for Action: • Get a

alert option is alsoproblems after a fall because they spent hours or days on the floor before someone came to check.

• Use a buddy system. Example 1.) Make an agreement with a family membeor friend to phone them each morning by a certain time, and if they have n

r

ot heard from you by that time, to come by to check on you. Example 2.) Make an agreement with a trusted neighbour that you will open your curtains by a certain time each morning. Otherwise, they will come to check on you or call someone for help.

MEQ ued

OBILITY & UIPMENT contin


1. Have you discussed all your medications (over the counter, herbal and prescription) with your doctor or pharmacist within the last 12 months?

Yes

No, then:

Meet with your doctor or pharmacist to review all your medications (over al and prescription, including puffers). Ask if any of your

ng

Ideas for Action: •

the counter, herbmedications may have an effect on your risk for falling.

• Make sure you know which medications you are taking, when to take them, and how to take them. TAKE THEM as prescribed. Note: It is a good idea to put all the medications you take in a bag to briwith you when you meet with your doctor or pharmacist.

2. Do you do a total of 30 minutes or more of physical activity each day? Yes

Some days

No, then:

herapist or other health care professional about ways to ome Activity Program. alking, extra “sit to

•e senior’s

buildings and through various community programs.

Ideas for Action: • Talk to a physiot

improve strength and balance, such as the SAIL HIncrease physical activity gradually by doing extra w• stands” or anything else that gets your body moving (e.g. try standing up every time a commercial comes on TV).

• Try to go for a walk each day. Walking is good and it can help m aintain muscle strength and balance. Two short walks may be easier than one longer one.

Participate in a group activity program. Stretch and strength exercises, tai chi, osteofit, dance and aqua fit classes are offered in som

3. Have your ey n checked this past year? es and vision bee

Yes

No, then: ch worse as we age. Have your

Ideas for Action: • For seniors, a vision assessment is recommended every 12

months. The risk of eye disease is muvision tested by your optometrist or ophthalmologist (specialist medical doctor).

Note: Donate old glasses that are no longer appropriate for you to CNIB or another non-profit organization.

TAKING CHARGE OF YOUR HEALTH


4. Are you able to sit up (from lying) or stand up without getting dizzy or light-headed?

Yes

Some of the time

No, then:

Ideas for Action: • Talk to your health care professional. Ask your doctor or nurse to take your

blood pressure when you are lying, sitting and standing. • Ask about your medications. • Don’t start moving when you first stand up. Wait a bit.

5. If you have had a fall in the past year, have you talked about it with

your doctor and/or other health care professionals? Yes

No, then:

Ideas for Action: • Discuss any falls with your doctor and other health care professionals. Ask

what more you can do to prevent future falls. • Consider hip protectors if you have had a fall that resulted in a fractured

bone or if you have osteoporosis. Hip protectors help prevent a fractured hip.

6. Can you always get to the toilet in time without rushing? Do you need to get up 3 or more times at night to use the toilet?

Yes

Some of the time

No, then:

Ideas for Action: • Ask your doctor or health care professional for suggestions that can work

for you (e.g. referral to continence specialist – nurse or physiotherapist). • Wear clothing that is easy to get down and pull up. • Train your bladder by going to the toilet every two hours during the day,

and then slowly try longer periods of time. • Drink lots of fluids during the day, but not after supper time. • Use appropriate incontinence products. There are many different types to

try. • Talk to your doctor or pharmacist if you have frequent urinary tract

infections (UTI) or bladder infections. Cranberry pills may be helpful. • Consider using assistive equipment such as a bedside commode or urinal at

night.

TAKING CHARGE OF YOUR HEALTH continued


7. Do you drink four or more glasses of fluid without caffeine daily?

Yes

No, then: Each day, drink four or more glasses of water or other fluids that do not .g., water, herb tea, juice, milk or de-caffeinated

.


contain caffeine (ebeverages). Fluids high in caffeine include most coffees, teas and soft drinks

8. Do you eat at least seven servings of fruits or vegetables each day? Yes

No, then:

•

• octor for a referral to a dietitian if you are concerned about your

Read the Canada food guide, and consider joining weight watchers or ous if you are overweight.

Ideas for Action:

Eat a well balanced diet every day that includes grain products, fruits, vegetables and enough protein. Ask your dweight or have special food needs (e.g., kidney disease, diabetes).

• overeaters anonym

• Phone Dial a Dietician at Health Link – just call 811 (no charge). • Talk to your doctor or pharmacist about whether vitamin D supplements are

right for you.

9. Do you do regular activities with other people?

Yes

Some of the time

No, then:

email).

rship

at can work for you. Note: Relationships are important for health and wellbeing.

Ideas for Action: • Keep in frequent contact with people who know you and care about you

(e.g. through phone calls, face to face visits, letters or• Participate in group activities like games, hobbies or interest groups. • Consider joining a social group (e.g., local seniors’ center, place of wo

or other organization of interest). • Ask your health care professional for suggestions th

10. Do you do regular activities that stimulate your brain?

Yes

No, then:

Ide• words, play

searches, learn to use the computer, computer games or

Note: Regular physical activity is important for brain and body health.

as for Action: Challenge your brain (e.g., learn a new activity or hobby, do crossscrabble, do wordprograms designed to improve brain health).

• Do regular physical activity.

TAKING CHARGE OF YOUR HEALTH continued


1. If you use stairs, can you see the edges of the steps clearly?

Yes

Don’t use stairs

No, then:

I

ng to make each

deas for Action: • Increase the lighting over the stairs. • Consider painting each step edge or adding a contrast edgi

step more visible. • Have your vision tested every year.

2. Do your stairs have sturdy, easy to grasp handrails on both sides?

Yes

Don’t have o

use stairs

r

No, then:

668-2642 or go to their

Ideas for Action: • Install sturdy, well-designed handrails on both sides of stairways. • Contact Canada Mortgage and Housing at 1 800

website www.cmhc.ca for publication 63637, “About your house: preventing falls on stairs”.

3. Do your stairs (both indoors and outdoors) have non-slip surfaces in good condition?

Yes

No, then: Ideas for Action: • plastic to protect carpets on stairs, remove it. Replace or

If you use smoothrepair damaged surfaces on steps.

4. Do you always feel safe and steady on your feet when using stairs or an elevator?

Yes

Some of the time

Don’t have or

use stairs

No, then:

g.

.

ed.

Ideas for Action:

Do more activities that improve strength and balance. • • Look to make sure the elevator is level with the floor before entering or

leavin• Take your time when entering or leaving an elevator. • Hold on to the handrail inside the elevator when the elevator is moving• Avoid using the elevator at busy times. Wait for another elevator if it is

overcrowd

STAIRS & ELEVATORS


1. Are the paths around your home or apartment building in good condition, an d grass trimmed and away from the d are all shrubs an paths?

Yes

N Ensure paths are maintained and clear. Ask or hire someone to do this. If

o, then: you live in an apartment, speak with the apartment manager.


2. Do all your outside paths drain water away properly so that water or ice does not collect?

Yes

No, then:

llect.

Ideas for Action: • Have someone mark the areas that collect water. • Ask or hire someone to repair those areas to ensure water does not co

3. Are hoses, garden tools and lawn furniture always kept away

from paths?

Yes

No, then:

Ideas for Action:

one to help store garden equipment • Ask or hire someaway from pathways and out of the way.

• If you live in an apartment, speak with the manager.

4. Are your pathways well lit, and is there good lighting at the main entrance to your home or building?

Yes

N• Ask or hire someone to install timed or motion sensor spotlights at

• If you live in an apartment, speak to the manager to get things fixed.

o, then: entrances, pathways and in hallways.

Ideas for Action:

OUTSIDE OF HOME


After you work through the SAIL Checklist and Action Plan, use this form to track your progress by placing a circle around a star for every question in the Checklist and Action Plan that you’ve answered “yes”.

Room

1 2 3 4 5 6 7 8 9 10

Bedroom

Living Room & Sitting Area

Bathroom

Dining Area & Kitchen

Lighting

Clothing & Footwear

Mobility & Equipment

Taking Care of Your Health

Stairs & Elevators

Outside of Home

TRACK PROGRESS

Question


This is your reminder of actions from your ay

healthy and safe. Checklist & Action Plan that you want to take to st

ACTION

COMPLETED BY

(DATE)

YOUR FALL PREVENTION ACTION LIST


Poster used with kind permission from East Berkshire Falls Prevention Services, UK

I have had a fall…

HOW TO GET UP AFTER A FALL

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