Fall protocol

[Kylee Renee]

All throughout PN school, it was drilled in my head that when a client/patient falls, the first priority is checking for injuries. Every test or assignment we took that had this question was counted correct if we chose "assess for injuries". At the end of the semester we had an ATI live review instructor come and review content for NCLEX, and she was adamant that in real life and on NCLEX the answer is always check the hemodynamics of the patient before anything else, so check vitals and what not.

My thinking is that you would want to assess for head injuries or bleeding, a broken leg, etc. Then do neuro checks and make sure they can move all extremities before you check vitals and get them up. My question is, what is the priority in this situation TEXTBOOK WISE, for NCLEX ( I take it monday), and what do you more experienced nurses typically do in real life for this situation? Thanks

[SoldierNurse22, BSN, RN]

I absolutely check for injuries first for the same reasons you listed. If a patient is seriously injured, you can't just pick them up off the floor. If they're bleeding, you're not going to plop them back in bed and get their vitals before you try to control the source of hemorrhage.

Sometimes in real life, both of these activities may be going on all at once--one nurse is taking vitals on the floor, the other one is checking for injuries, etc. However, in NCLEX-land, you have to assume you're the only one there unless told otherwise. Personally, if I found a patient on the floor, my first thought wouldn't be vital signs. It's not only instinctive but the safe option to ensure that your patient is not so injured as to contraindicate a move to bed without further assistance/diagnostics.

[cowboy up]

Absolutely you check for injuries first and if they are complaining of head or neck pain they are not moving until I've spoken to a doctor or I get a c collar around their neck.