Immediate Response and Patient Stabilization
The first and most critical step following a patient fall is to ensure their immediate safety and stability. Before attempting to move the patient, it is essential to perform a rapid assessment to identify any immediate, life-threatening injuries, such as severe bleeding, head trauma, or spinal injury.
- Do not move the patient immediately: If a head or neck injury is suspected, immobilize the cervical spine. A shortened or externally rotated leg may indicate a hip fracture and also requires careful handling.
- Stay with the patient and call for help: A second person can help gather supplies or notify a senior clinician.
- Assess ABCs: Check the patient's airway, breathing, and circulation. If the patient is unconscious, not breathing, or pulseless, initiate emergency protocols and begin CPR.
- Perform a visual and verbal assessment: Ask the patient what happened and if they are experiencing any pain. Observe their overall demeanor, skin color, and look for visible injuries like cuts, bruises, or deformities.
Comprehensive Post-Fall Physical Examination
Once the patient is stabilized, a more thorough head-to-toe physical examination should be conducted to identify any injuries sustained during the fall. This systematic approach helps prevent missed injuries that could lead to serious complications.
Assess Vital Signs and Orthostatic Hypotension
Take a full set of vital signs, including temperature, pulse, respiration rate, and blood pressure. A key component is checking for orthostatic hypotension, which is a significant risk factor for falls.
- Measure blood pressure and pulse while the patient is lying down, then again at 1 and 3 minutes after they stand up.
- A drop of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure indicates orthostatic hypotension.
Neurological Examination
A head strike can have delayed symptoms, so a comprehensive neurological exam is mandatory, especially for unwitnessed falls. Frequent reassessments should be scheduled for the next 24-72 hours.
- Level of Consciousness: Assess for any changes in alertness, confusion, or orientation. Use tools like the Glasgow Coma Scale (GCS) as needed.
- Pupillary Response: Check pupils for size, shape, and reactivity to light.
- Motor and Sensory Function: Assess strength, sensation, and movement in all four extremities. Look for numbness or tingling.
Musculoskeletal and Integumentary Assessment
- Extremity Assessment: Palpate all four extremities for pain, swelling, and deformity. Look for an externally rotated and shortened leg, which is a classic sign of a hip fracture.
- Spine and Pelvis: Gently palpate the spine and pelvis, noting any tenderness or bony deformities. Log-rolling may be necessary to inspect the back, maintaining spinal precautions if injury is suspected.
- Skin Assessment: Perform a thorough skin check for lacerations, abrasions, bruises, and skin tears. Note any areas of pallor or cyanosis.
Investigating the Cause and Implementing Interventions
Identifying the contributing factors to the fall is crucial for preventing future incidents. The investigation should go beyond immediate injuries to understand the context of the event.
Document the Fall and Interview Witnesses
- Circumstances of the fall: Gather information on the who, what, when, where, and why of the fall. What was the patient doing? Where did it happen? What was their reported feeling just before the fall?
- Patient interview: Ask the patient to describe what happened in their own words. Did they feel dizzy? Did they trip? Did they lose consciousness?
- Witness interview: If the fall was witnessed, gather an account from the observer.
Review Risk Factors and Care Plan
Review the patient's history and current risk factors for falling. This should be a multidisciplinary effort, involving physicians, nurses, physical therapists, and occupational therapists.
- Medication Review: Review all medications, including over-the-counter drugs, for potential side effects that increase fall risk, such as drowsiness or orthostatic hypotension.
- Assess Cognition: Perform a cognitive screen to check for altered mental status, which can affect judgment and awareness.
- Environmental Assessment: Identify any environmental hazards in the patient's living space, such as poor lighting, loose cords, or slippery floors.
- Mobility Assessment: Use standardized tools to evaluate gait, balance, and lower-body strength. The Timed Up and Go (TUG) test is a quick and effective screening tool.
Comparison of Common Fall Risk Assessment Tools
| Assessment Tool | Primary Focus | Best For | Score Indicating High Risk | Notes |
|---|---|---|---|---|
| Morse Fall Scale (MFS) | History, secondary diagnosis, mobility, mental status | Hospital settings and geriatric wards | Scores over a certain threshold (often 45) | Evaluates multiple factors with a cumulative score. |
| Timed Up and Go (TUG) Test | Mobility, balance, gait | Quick, office-based screening | ≥ 12 seconds | Simple, validated test. Observation of gait is key. |
| Berg Balance Scale (BBS) | Static and dynamic balance | Detailed balance evaluation | < 45 out of 56 | Includes 14 specific tasks to assess balance control. |
| STEADI Initiative | Comprehensive risk assessment and intervention | All older adults | Yes to key screening questions | A coordinated approach with resources for screening, assessing, and intervening. |
Conclusion: From Crisis Management to Prevention
Knowing how to assess a patient who has fallen involves more than just treating immediate injuries; it is a critical opportunity for a comprehensive evaluation and effective risk management. By following a structured, evidence-based approach that includes immediate stabilization, a thorough physical and neurological exam, and an investigation into contributing factors, healthcare providers can make informed decisions. The goal is to move from reactive crisis management to a proactive strategy that addresses modifiable risk factors like medication, mobility, and environmental hazards. This not only improves patient outcomes and prevents recurrent falls but also enhances the overall quality of care. The use of standardized assessment tools and ongoing monitoring for 72 hours post-fall are vital components for ensuring long-term patient safety.
Key Takeaways
- Immediate action is crucial: First, assess for life-threatening injuries and stabilize the patient before attempting to move them.
- Do not assume no injury: Even a seemingly minor fall can cause internal or delayed injuries, so a comprehensive head-to-toe assessment is mandatory.
- Check for orthostatic hypotension: A change in blood pressure upon standing is a key modifiable risk factor for future falls.
- Investigate underlying causes: A fall is a symptom of an underlying issue; review medications, assess cognition, and check for environmental hazards.
- Use standardized tools: Incorporate tools like the TUG test or the Morse Fall Scale to systematically evaluate balance and risk.
- Monitor for 72 hours: Closely monitor the patient for a minimum of 72 hours following the fall to detect any delayed symptoms.
- Educate and intervene: Tailor interventions based on identified risk factors and educate the patient and family on fall prevention strategies.
