Complicated issue re: a fall

[marjoriemac, LPN]

A resident in my home was found lying face down on the floor in his room with a wound on his head and bruising to his left wrist/knee/head/elbow. The man said he was in no pain and was assisted to sit. Wound cleared up and GP consulted via telephone. GP says if man is not in pain (which he repeatedly said he wasnt) and if he could move limbs (the man never lifts his arms anyway but wrist could be rotated and elbow straightened without evident pain), then unlikely to be fractured or dislocated as this would be agony. He did not visit but advised to give analgesia if required and observe. By 2pm the man still insisted he was in no pain but would not move left arm (particularly at elbow and shoulder), I phoned the GP again and a different doctor advised to send for x-ray.

My problem is with my colleague she thinks the man is just scared and wont admit pain and I should therefore have given him analgesia even though he did not want any when I asked. She said the man has history of osteoporosis (this is not in his notes) and the GP should have sent him to hospital straight away. I however agreed that in the circumstances he was right to wait as I have had residents go to A&E unnecessarily before and have to wait 4 hours to be seen and 8 hours to get an ambulance back. When I left work, the ambulance still had not arrived but the man was watching television in his room and spoke pleasantly to me as I entered. If this man was n agony I take my hat off to him. What would others have done!

PS I done 15 minute checks on him for 4 hours following the fall to check for head injury, he was alert at all times and blood pressure and pulse normal.

[Jolie, BSN]

A resident in my home was found lying face down on the floor in his room with a wound on his head and bruising to his left wrist/knee/head/elbow. The man said he was in no pain and was assisted to sit. Wound cleared up and GP consulted via telephone. GP says if man is not in pain (which he repeatedly said he wasnt) and if he could move limbs (the man never lifts his arms anyway but wrist could be rotated and elbow straightened without evident pain), then unlikely to be fractured or dislocated as this would be agony. He did not visit but advised to give analgesia if required and observe. By 2pm the man still insisted he was in no pain but would not move left arm (particularly at elbow and shoulder), I phoned the GP again and a different doctor advised to send for x-ray.

My problem is with my colleague she thinks the man is just scared and wont admit pain and I should therefore have given him analgesia even though he did not want any when I asked. She said the man has history of osteoporosis (this is not in his notes) and the GP should have sent him to hospital straight away. I however agreed that in the circumstances he was right to wait as I have had residents go to A&E unnecessarily before and have to wait 4 hours to be seen and 8 hours to get an ambulance back. When I left work, the ambulance still had not arrived but the man was watching television in his room and spoke pleasantly to me as I entered. If this man was n agony I take my hat off to him. What would others have done!

PS I done 15 minute checks on him for 4 hours following the fall to check for head injury, he was alert at all times and blood pressure and pulse normal.

I think you acted very prudently. You thoroughly assessed the man, consulted with the physician, continued to monitor very closely for complications of the fall, and acted appropriately when you detected one.

You offered pain medication, which he declined. You can not force medication on him against his will.

I applaud you for not rushing the man off for emergency treatment when it was not apparently necessary. I think many people fail to understand or consider the potential for discomfort and exhaustion on the resident's part when they are forced to wait for hours in an emergency waiting room.

You did fine!

[gonzo1, ASN, RN]

Sounds like you did a good job. I wouldn't worry about what the other nurse says as long as you feel pt didn't want pain meds no need to push them on him. Continue to monitor as head injuries can cause problems months later in the elderly due to small vessel bleeds.

[donmomofnine]

Sounds wise to me!

This is a good situation for a portable xray, though, if available.

[banditrn]

I also think you did the right thing - I'd be a little nervous about pushing pain meds on a person who may possibly be a head injury - they don't always show up right away.

[meownsmile, BSN, RN]

I think you acted correctly too. I would have done the same and more than likely would have been more concerned with the head wound initially. But if neuro was continuing to be unchanged and he wasnt showing any symptoms of altered mental status, not complaining of any extremity pain or pain anywhere else you did the right thing.

I work ortho and ive seen people come in 2 weeks after falls with fractures of the hip and go to surgery for repair. So really if they arent complaining and not showing any favoring of anything you cant presume there is a fracture and have films made. Good job!!

[TrudyRN]

I think you did right. How is he now?

[marjoriemac, LPN]

Just an update, the man in question has been found to have a suspected fractured collar bone after attending A&E in the afternoon when I noticed he was not using his arm but still he said no pain. The diagnosis is suspected as the man would not sit adequately for the x-ray and it was not clear, he also does not move his arms at the best of times so a thorough assessment was difficult. The hospital staff also commented on his lack of pain. After 8 hours in casualty he returned with a collar and cuff and advice to give analgesia if requested. I'm happier now, beginning to think the other nurse just does not like me because I have formed a relationship with 'her' residents! Thanks guys!