Published Aug 1, 2011
beeble
100 Posts
If so, what is it? At ours, we complete a fall paperwork, an incident report, and are supposed to have a post fall huddle.
TheCommuter, BSN, RN
102 Articles; 27,612 Posts
If the fall was unwitnessed, the patient admits to striking his/her head, or there's evidence of head injury, we are also to do neuro assessments regularly until 72 hours elapses.
We complete an incident report, a post-fall assessment, a revised fall risk score, and notify the physician and next-of-kin.
nurse955
53 Posts
A CT scan is part of the order if there is any doubt or concerns regarding if the pt hit his head or not. Based on the post fall assessment score, interventions are implemented such as moving closer to the nursing station, bed or chair alarm, 1:1 sitter, or lower height bed with foam padding next to the bed on the floor.
Tait, MSN, RN
2,142 Posts
Stabilize the patient, call the doc, notify the house supervisor, notify charge nurse, call the family, assessments Q2 hours of no head injury witnessed, Q1 hour if head injury witnessed/questionable, complete fall report (unusual occurrence), charting.
That Guy, BSN, RN, EMT-B
3,421 Posts
Basically this.
loriangel14, RN
6,931 Posts
We do an incident report, nursing note, post fall assessment,notify family and MD.