Immediate Priorities: Safety and Stabilization
When a fall occurs, the immediate priority is to ensure the safety and stability of the patient. Before any attempt is made to move the individual, a crucial, rapid assessment must take place. The first step involves checking the patient's airway, breathing, and circulation (ABCs).
Airway, Breathing, and Circulation (ABCs)
Upon discovering a patient who has fallen, a nurse must first determine their responsiveness and check their vital signs. If the patient is unconscious, not breathing, or without a pulse, an emergency code should be called immediately, and CPR initiated according to facility protocol. This initial phase is about life preservation and requires immediate, decisive action.
Checking for Life-Threatening Injuries
Beyond the ABCs, the nurse must quickly scan for immediate, life-threatening injuries. This includes observing for significant bleeding, obvious deformities suggesting fractures, or signs of head or neck trauma.
- Spinal Precautions: If there is any suspicion of a head, neck, or spinal injury, the patient should not be moved. Specialized teams, such as EMS, should be called to handle immobilization and transport.
- Consciousness Assessment: Observe the patient's level of consciousness and check for any loss of consciousness, confusion, or disorientation, as these can indicate a head injury.
- Pain Assessment: Ask the patient if they are experiencing any pain and note its location and intensity. This is a key indicator for potential injuries, especially fractures.
The Comprehensive Head-to-Toe Assessment
Once the patient is stabilized, a detailed head-to-toe physical examination is necessary to identify all potential injuries, from minor abrasions to major fractures.
Neurological Evaluation
- Level of Consciousness: Beyond the initial check, a more thorough neurological assessment is performed. This includes using a standardized tool like the Glasgow Coma Scale and monitoring for any subtle cognitive changes.
- Pupil Assessment: Check the patient's pupils for size, equality, and reaction to light, which can reveal neurological status.
- Motor and Sensory Function: Assess the patient's ability to move all four extremities and their sensation to touch. Report any numbness, tingling, or weakness.
Skin Integrity and Musculoskeletal Examination
- Visual Inspection: Look for any trauma, such as bruising, abrasions, lacerations, or skin tears. It's crucial to check all areas, including the head, neck, trunk, and extremities.
- Palpation: Gently palpate bony areas and major joints to check for pain, swelling, or deformity, which could indicate a fracture. Special attention should be paid to the hips, as a shortened and externally rotated leg is a classic sign of a hip fracture.
Cardiovascular and Respiratory Evaluation
- Vital Signs: Re-check vital signs, including blood pressure, pulse, and respiration rate, comparing them to the patient's baseline. Orthostatic blood pressure changes should also be checked.
- Chest Assessment: If the patient reports chest pain or difficulty breathing, assess for potential rib fractures, which can cause asymmetrical chest movement.
Investigation and Documentation
A thorough assessment extends beyond the patient's physical state to the circumstances surrounding the fall. This is crucial for prevention and legal documentation.
Circumstances of the Fall
Gather as much information as possible about the fall, including:
- What was the patient doing? Were they attempting to get out of bed, go to the bathroom, or reaching for an item?
- What were the environmental factors? Was the floor wet, were call lights within reach, or was there clutter in the area?
- Witnesses: Was the fall witnessed? If so, what did the witness observe?
- Patient's Account: If possible, ask the patient what they remember. Did they feel dizzy or weak beforehand?
Comparing Post-Fall Care with Preventive Measures
Effective post-fall assessment also involves reviewing and adjusting preventive measures. The following table compares standard procedures with post-fall modifications.
| Assessment Area | Standard Procedure | Post-Fall Adjustments |
|---|---|---|
| Monitoring Frequency | Standard shift checks | Increased neurological and vital sign checks for 72 hours |
| Medication Review | As per routine schedule | Immediate review of medications, especially sedatives, psychotropics, and anticoagulants |
| Mobility Assistance | As per care plan | Immediate reassessment of mobility needs and increased assistance levels |
| Environmental Scan | Routine room checks | Focused investigation of the fall location for specific hazards |
| Care Plan Updates | Periodic reviews | Interdisciplinary team immediately revises the care plan based on new findings |
Documentation
Comprehensive and objective documentation is a legal necessity. This includes recording the time of the fall, the assessment findings, communication with the provider, and any interventions implemented. Documentation should be objective and factual, avoiding assumptions.
For additional guidance on falls management, including the use of standardized assessment tools, consult resources from the Agency for Healthcare Research and Quality (AHRQ).
Ongoing Monitoring and Reassessment
The initial assessment is just the beginning. The patient must be closely monitored for changes in condition for at least 72 hours post-fall. During this time, nurses should continue to perform neurological and vital sign checks and be vigilant for any delayed symptoms, such as worsening confusion or pain. This proactive monitoring ensures that any internal or slowly developing injuries are caught and treated promptly, preventing potentially fatal outcomes.
Conclusion
Knowing what to assess after a fall in nursing is not merely a procedural task; it is a critical skill that saves lives. A structured, comprehensive approach—from immediate stabilization and head-to-toe assessment to thorough investigation and documentation—is vital. This process ensures immediate injuries are addressed, and more importantly, identifies underlying causes to prevent future incidents, embodying the core principles of proactive, person-centered senior care. By following a clear protocol, nurses can significantly enhance resident safety and provide the highest standard of care.
