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Fundamentals: falls, pressure areas and MUST

RCSI heading: Fundamentals of nursing care. You get 2 minutes with the descriptor outside the door and 10 inside, marked competent or not competent on every line. RCSI publishes no sample for this station; the descriptor below follows the layout of the two samples it does publish. Check rcsi.com before your date.

Rehearse it

Stand up, say it aloud, use whatever is on your desk as the equipment. The debrief is the competency sheet and the assessor’s questions.

Reading time
Outside the door. Two minutes with the descriptor, then in.
2:00
Purpose

To assess the risk assessments that start every admission: falls, skin and pressure areas with the Waterlow score, and nutrition with MUST, and the care plan that follows from each.

Situation / scenario

Mrs Eileen Murphy, 83, admitted this morning from home after a fall in the bathroom. She has a history of osteoarthritis, takes a night sedative, and her daughter says she has "gone off her food" and lost weight over the summer. Height 1.60 m, weight 48 kg, weight three months ago 53 kg. Sacral skin is red but intact.

You are required to complete the falls risk assessment, the Waterlow chart and MUST from the information given, explain each score, and state the care plan for each.

You are required to
  1. Hand hygiene, introduce yourself, check the identity band, gain consent for the assessments
  2. Take a falls history: how many falls in the last year, how it happened, injury, fear of falling, medication (sedatives, antihypertensives), vision, footwear, continence
  3. State the falls prevention plan: bed at the right height, call bell in reach, non-slip footwear, walking aid, lighting, toileting plan, medication review, no bed rails as a restraint
  4. Score the Waterlow chart line by line: sex, age, BMI, skin type, mobility, continence, MUST, special risks, and total it
  5. Explain the bands: 10 or more at risk, 15 or more high risk, 20 or more very high risk, and when the chart is repeated
  6. Name the pressure areas at risk: sacrum, heels, ischial tuberosities, trochanters, elbows, shoulder blades, occiput, ears under oxygen tubing
  7. State the SSKIN care bundle: surface, skin inspection, keep moving, incontinence and moisture, nutrition and hydration
  8. Calculate MUST: BMI score, unplanned weight loss score, acute disease effect, total and risk category
  9. State the MUST care plan: food record chart, dietitian referral, snacks and supplements as advised, weekly weight
  10. Document all three assessments, sign and print your name, say when each is due again

Throughout: communicate in an accurate, clear and effective manner; demonstrate a level of competence essential for safe practice.

The descriptor, the mistakes and the sources on this page are free to read. The timed run, the competency sheet and the assessor’s questions need the pass. Two stations run free in full: respiratory and observations, INEWS and ISBAR.

The pass: theory and OSCE

Run every station on the clock.

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Competencies assessed

Every RCSI descriptor lists the same five domains from the NMBI standards.

  • Professional values and conduct of the nurse
  • Nursing practice and clinical decision-making
  • Knowledge and cognitive competences
  • Communication and interpersonal competences
  • Management and team competences

Mistakes candidates report

  • Scoring Waterlow from memory and getting the BMI band wrong: below 20 is 3, not 1.
  • Forgetting MUST is a line on the Waterlow chart, so it has to be done first.
  • Saying "two-hourly turns" for everyone. The plan follows the score and the skin check.
  • Bed rails as a falls measure. They are a restraint and a climbing hazard.
  • Assessing and not saying when it is repeated. Every assessment has a review date.

Practise the parts

Sources

This descriptor is a practice piece written to the shape of the RCSI samples. It is not an exam task, and the exam may ask anything from the reading list.

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