Immediate Post-Fall Evaluation of the Older Patient
Immediate Post-Fall Evaluation of the Older Patient
Mrs. Alamo was admitted to Goodcare Nursing Home last week with moderate-stage dementia, osteoarthritis, osteoporosis and a history of multiple strokes resulting in right-sided weakness and unsteady gait. She has been identified as being at high risk for fall-related injury.
The occupational therapist has provided her with a hemi-height wheelchair and a right-sided lateral support cushion and seat cushion.
While in the hallway, another resident stood in front of Mrs. Alamo's wheelchair and began to verbally harass her. Mrs. Alamo became upset and attempted to get out of her chair to push the other resident away from her. She fell and began to cry out for help.
When you arrived on the scene, Mrs. Alamo was lying on her right side on the floor. You begin your assessment by considering common fall-related injuries among the elderly.
Many different types of trauma, including muscoskeletal injuries, can result from a fall. Hip fractures are the most common. Head and neck injuries including subdural hematoma are the second most common type of injury. Dislocation injuries of the cervical spine, shoulder and hip are also important to consider.
This article focuses on the physical examination of older persons who have fallen in the non-acute care setting such as a nursing home or psychiatric hospital.
The first priority is the assessment of basic life support, i.e., airway, breathing and circulation. Evaluation of disability and identification of injuries comes second, followed by evaluation of the underlying cause(s) of the fall.
A fallen person should not be moved until a complete and thorough examination has been performed to rule out cervical or thoracic spine injury. Once it is clear that the patient is stable, query about the presence of pain, and ask the patient/witness how they fell, about shortness of breath and about any significant preceding event such as syncope, palpitations or chest pain.
Begin monitoring the patient's level of consciousness, measure vital signs, pulse oximetry (POX), and blood glucose (especially if there is a history of diabetes or hypoglycemia). These measurements should be taken at least every 15 minutes as well as with any drastic change in status (for example, loss of consciousness or new onset of confusion or agitation).
Slide your hands along the patient or resident's entire body with a firm but gentle pressure using a systematic head-to-toe approach. Feel for deformities and watch the patient's face for expressions of pain.
Check the head, ears, eyes, nose and throat for lacerations, bruising or bleeding. Any tenderness with palpation of the cervical/thoracic vertebrae or acute change in neurological status suggests a spinal or closed head injury that requires head stabilization and oxygen through a non-rebreather mask.
Inspect the patient's chest and abdomen for asymmetrical chest movement, rapid, shallow breathing, use of accessory muscles and/or tenderness of chest that may indicate a rib fracture or respiratory distress.
If chest pain is only elicited with pressure applied to the sternum, then a rib fracture instead of a cardiac cause is likely. If chest pain is present without pressure, radiates to the neck, jaw, left arm and/or is accompanied by shortness of breath, nausea/vomiting or lightheadedness, obtain an EKG and provide oxygen via a non-rebreather mask at 15.0 liters of flow. Auscultate lung sounds and if absent, consider airway obstruction, pleural effusion or pulmonary edema. If POX measurements are 93 percent or less, provide oxygen, initially via nasal cannula.
A firm, distended or tender abdomen may suggest internal bleeding, peritonitis or bowel obstruction. Assess for a pelvis injury by applying pressure to both iliac crests while moving the hips forward and backward. Any pain or crepitus (a feeling of grating with movement) may mean a pelvic fracture.
Assessment for Hip Injuries
A fractured hip will cause the involved extremity to be shorter than the other extremity and externally rotated. A dislocated hip is usually internally rotated and slightly flexed. Lower-extremity fractures include the distal tibia and proximal fibula, and may present with an avulsion fracture of the medial malleolus.
Fracture of the proximal humerus may also be accompanied by a dislocation of the involved shoulder. The patient will often complain of pain and tenderness and there is frequently a large bruise in the fracture area that may spread into the pectoral region.
A Colles' fracture of the distal radius and ulna will frequently present with an obvious "dinner fork" deformity; a dorsal depression and volar wrist fullness.
Cervical stabilization and adjunctive oxygenation is necessary for all unresponsive patients and those suspected of having a head injury or spinal fracture. Any possible fracture should be immobilized in a position of comfort to reduce pain and decrease the risk of additional damage to the injury site. Splint all fractures so that the joints above and below the injury site are immobilized.
For suspected fractures of the hip and pelvis, long board immobilization is required. Keep these patients on the floor until long board immobilization can be provided. Support of upper extremity fractures can be provided with a sling. Evaluate the motor/sensory function and circulation of the portion of the extremity distal to the fracture. Decreased/absent neurologic function or circulation indicates nerve or vessel involvement and should be treated as a true emergency.
Only those with specific emergency transfer training should apply immobilization devices (cervical collars, backboards and splints) since improper application can result in injuries. Otherwise, provide cervical stabilization by simply maintaining the head in an anatomically correct position by applying equal pressure to both sides of the mandible while supporting the back of the head (occipital region) with the third and fourth fingers of each hand. This stabilization must be maintained until a cervical collar is in place and the head is fully immobilized.
Finally, careful monitoring of vital signs can provide timely evidence of shock (decrease in blood pressure with an increase in heart and respiratory rate). Bleeding secondary to a hip fracture or injury to the abdomen or aorta can lead to hypovolemic shock. Immediate elevation of the lower extremities can improve circulation to the brain. Infusion of volume expanders depends on institutional protocols.
In a non-acute care setting such as a psychiatric hospital, nursing home, assisted living or adult day care facility, a nurse is often the first professional to evaluate a potential fall-related injury. A thorough yet quick physical evaluation can reveal conditions requiring immediate attention or interventions to prevent further injury. Appropriate treatment prior to the arrival of a fire/rescue team or contracted ambulance company can positively affect the patient's outcomes.
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Gerald Driscoll and Elizabeth Capezuti are gerontological nurse practitioners and consultants in fall prevention and management. Driscoll has worked extensively in pre-hospital settings, emergency and ICU departments in the Philadelphia area. Dr. Capezutti is an associate professor at the Emory University School of Nursing, Atlanta.