Post-Fall Neuro Exam

[ckd4035]

I am a new grad RN on a LTC unit, and in case of a fall I am responsible for examining the resident and determining whether or not it is safe to move him or her. Most of my training was held in hospital settings, where I would not have been the most qualified to do this, and I have never witnessed a fall (and, more importantly, what happens afterwards). Does anyone have any neuro check they would use in these situations? Specifically, how would I determine if it is safe to move them? I know the basics otherwise (monitor for increased ICP, notify the supervisor, etc), but unless there is a bone sticking out of their neck, I'm not confident I would know whether or not they can moved immediately.

[kiszi, RN]

Post fall, I'll get a set of vitals, assess for injuries, ask if the resident can tell me about the fall and if there is any pain, check ROM to extremities, and then get them up. For unwitnessed falls or witnessed falls if the resident bumped their head, neuro checks are initiated. This includes LOC, pupil check, push/pulls and hand grasps. We use a standardized sheet, there are a couple of other check offs that I don't recall.

[kiszi, RN]

When they cannot be moved immediately it becomes obvious quickly. Listen to your residents! I had a fall in LTC years ago where the lady yelled out when ROM to her leg was attempted. She had a hip fx.

[bluegeegoo2, LPN]

I have them do AROM to all 4 extremities if they are able. If not, I'll do slow and careful PROM after a looking them over for any signs of obvious trauma. Of course I ask if they hurt anywhere while performing any of the above. I watch their response when brought up to weight bearing. If they normally don't bear their own weight I watch for response when seated back in a w/c or bed for possible hip/pelvis/back injury if the AROM/PROM's were negative for guarding/pain response. I feel and look at their head for lumps/bumps/soft spots or new discoloration. Pupil reaction and equal? Push/pulls/grips, orientation? If all checks out ok at this point, they are then monitored for excessive sleepiness, c/o N/V, AMS, etc. for 72 hrs post fall.

[dream'n, BSN, RN]

Just a couple of additions; be extra cautious assessing your patient's that are on anticoagulation therapy, especially if a fall is unwitnessed, the patient hit their head, or the patient has confusion as a baseline. I work acute care, but in those cases patient's almost always get a STAT head CT since they are at higher risk for bleeding of the brain; even if they are without symptoms at the time. Also pay close attention to the joint areas for pain/swelling/redness, such as the hips, knees, wrists, elbows, etc.