What would you do?

[the_alchemist]

Please share your response on this scenario:

Demented geriatric patient fell on concrete floor from wheelchair, sustained a laceration near the corner of the eye and bleeding was controlled. c/o pain in injured area. He is able to mention his name when asked. He is disoriented to time and place, same as baseline. He moves his hands as he has been known to do. Vital signs stable.Neuroassessment done. Pupils round and equal, able to follow objects. No distortion in the face. No fluids coming out of facial openings. Able to move extremities when instructed to do so. Grasps hands when asked to do so, equal. No episode of unconsciousness, no seizure, no sign of distress.

[the_alchemist]

Going back to this case, let me write down more info about this patient pre-fall

he was non-ambulatory with 1-person assistance with transfers

he had a fall 6 days before, in the fall, he fell on his rear end, pelvic x-ray done without any fracture

he has history of cerebral bleed

he was taking ASA 81 mg PO daily

[Kitty]

I would have put on a C-collar and called an ambulance.

[noreenl]

After the last update on the patient's hx I would have done the same as JulietteP. Recent hx of fall (less than a week) and hx of CV bleed and on daily aspirin therapy; each by itself would make me really consider 911, but all 3; He was going to the ER by ambulance ASAP. I would have left him right where he was and covered him and monitor V/S and neuro checks q 15 min and then turn him over to Emergency staff that responded. They would document position of patient and picked him up off floor and place on stretcher. It would be back up documentation for me; from an outside source, as the RN in charge at the time of the incident.

I have learned from 15 yrs as a union rep for nurses that CYA is always the best policy, unfortunately paperwork written at the time of an incident can be a problem because we are involved in the moment. I tell my nurses NEVER write a report until you take 15 min for yourself and just free wrtite details then walk away for 15 min THEN come back and write your report and I don't write it on the form the first time either! Thank God for scrap paper! Also, I have found that having an "outside" coroborating(sic) source has saved me before! Police EMT Fire Dept

[jrbl77, RN]

from a completly other view, was the family involved or contacted about the fall and if so how soon? As a nurse and child of a resident of a LTC I would be interested in that view. It is so hard to look back and try to think of how you would/could have better handled such a situation. I'm sure that the nurse involved has this fall on her mind all the time.

[queen777]

Please share your response on this scenario:

Demented geriatric patient fell on concrete floor from wheelchair, sustained a laceration near the corner of the eye and bleeding was controlled. c/o pain in injured area. He is able to mention his name when asked. He is disoriented to time and place, same as baseline. He moves his hands as he has been known to do. Vital signs stable.Neuroassessment done. Pupils round and equal, able to follow objects. No distortion in the face. No fluids coming out of facial openings. Able to move extremities when instructed to do so. Grasps hands when asked to do so, equal. No episode of unconsciousness, no seizure, no sign of distress.

I just think your charting could use a little help. I was taught to report those things that the pt didn't come in with. Ex. Foley catheter, IV fluids. etc. I once heard a doctor remark when reading a pt's chart, "don't give me a creative writing paper to read, just the facts."

Unconsciousness, seizures, ....or you could say, oriented to person, place, and time or not ,and lists that. Not "no fluids coming out of facial openings". I think I know what you are saying, but some of your remarks are wide open to anything, such as "same as baseline."

Whoever reads your incident report will have to go back to the chart or ask you what that means.

What caused the fall? Was he supposed to be wearing a constraint such as a lap belt and wasn't ?

Also mention what you are going to do later, which would be get vitals q15min, q30m, q2h for 2 hrs, then q4h, let them know as a nurse what you are going to be doing to prevent this from happening . Each facility has its protocols for falls and what you should do afterwards. Ex. Neuro checks q15min. for an hour, What does vital sign stable mean? Just get the vital signs. Nurses don't diagnose, they report what they see and let the doctor know if anything is remarkable or not. I think in most cases after calling the doctor he would give you an order to have the pt sent out. In that case, leave him on the floor covered, and put a rolled up blanket under his head. so much could happen in the later hours, head wounds are very ify.

You said he had a hx of falls, did he have an order a lap belt? Maybe you don't or can't use restraints in your state, it depends.

What kind of pain does he c/o, stabbing, throbbing, constant, what is the pain on a scale from 1 -10? Instead, he obeys verbal commands by sweezing my hands, pupils equal in size and nondilated, ears and eyes clear of any fluids, he is either oriented or not to time, place and person, respirations even and unlabored?

You get the point. Did you call both the doctor & and chart his orders? Also the family to let them know and chart every thing you did as well ex. dressing to wound, and what kind, how did you clean the wound?

I worked as a geriatic nurse for 8 years. It's hard & busy work. Good luck!

[RNCCMMS, RN]

I agree with CamaroNurse...whenever anyone hits their head especially a senior citizen, think subdural hematoma. In this case since the patient was not able to verbalize a headache or be evaluated for confusion due to being disoriented as a baseline, I would have sent to the er with R/O SUBDURAL HEMATOMA. I would not have considered this a life or death event at the time of occurrence, but would stress to everyone involved, that the patient hit his head.

I saw a similar case where the patient was alert, complained of a headache, after a fall from a hoyer lift, striking her head. She was sent to the ER after the fall initially who sent her back after the cat scan. The facility put her on neuro checks q15minutes. She complained to the staff about a headache, was given Tylenol. She was then given Darvocet despite deteriorating neuro checks which were never reported to the physician who was called. She became unresponsive, then was sent to the ER again where she expired one hour later due to a subdural hematoma.

Don't beat yourself up over this..look at it as a learning experience. We have all had untoward events happen to our patients despite our best intentions.

[Lindsey McGraw]

After 17 years of every capacity in LTC management (superviser for 12 of these years 3-11) my advice is always error on the side of caution. Head injuries in my facility -we sent them to the ER for a CT scan...because subdural bleeds do not present right away symptomatically. When we call our Dr's their usual response is to order just this action. Maybe we are over-reactive but many times my resident has not come back when sent 911/admitted so call was a good one.

What really got my attention was the fact fell from a w/c to a cement floor which is most unforgiving!

[LaneRN]

I work in a LTC facility and our protocol is that any time there is a head injury of any type we send the patient out. most of the time by non emergent transport but our nonemergent transporters are usually pretty quick to pick our residents up. Unless it is a really terrible bleed and we had reason to believe that the resident needed to go 911 this is usually our protocol. Our facility believes that its better to be safe than sorry,.

[Lindsey McGraw]

Since demented residents present with symptoms often masked - my judgment call would have been send to the ER for a CT-scan. At our facility we error on the the side of caution mainly because a "cement floor" is most unforgiving. A slow subdural bleed takes time to manifest and then it might be to late. Often I am surprised (upon transfer not presenting with any specific/life threatening signs/symptoms) when the resident does not return but is admitted with a definite problem requiring a varying hospital stay.

As far as calling 911 I am specific what my problem is because it makes a difference if they send two ambulances/teams or a transport team (all EMT's). When talking to dispatch always state "fall, alert, no loss of consciousness)" or whatever but reason you are sending them for evalution ie: "fell from a wheelchair etc." They are appreciative because does not tie up ambulances that may be needed for other calls since this is a big city. We have a lot of volunteer crews so sometimes they are dispatched.

[Lindsey McGraw]

Whoops!, think I am developing a form of half timers real bad. Did not remember posting on this article in the past...DA..should have read all the comments before?

:)

[countrydot]

I had a Night like that to send or not to send. It wasn't a fall but one very bad copd-er had a little more then normal sob and then had projectile emesis that shot over to his roommates bed. LTC BP was 207/110 I 911'd him out . Less then 10 minutes later the CNA'S tell me another man had thrown up. He was cold and clammy always had difficulty clearing his airway emesis looked like coffee grounds called Dr sent him out by ambulance. The first was full code second was DNR I felt they both needed to be sent but wondered if I sent the wrong one 911. I'm an LPN and the only nurse in the building at noc

[kbrn2002, ADN, RN]

I had a Night like that to send or not to send. It wasn't a fall but one very bad copd-er had a little more then normal sob and then had projectile emesis that shot over to his roommates bed. LTC BP was 207/110 I 911'd him out . Less then 10 minutes later the CNA'S tell me another man had thrown up. He was cold and clammy always had difficulty clearing his airway emesis looked like coffee grounds called Dr sent him out by ambulance. The first was full code second was DNR I felt they both needed to be sent but wondered if I sent the wrong one 911. I'm an LPN and the only nurse in the building at noc

Actually I would have 911'd both of those. Dyspnea and projectile emesis are pretty common symptoms of cardiac arrest even without that sky-high BP, and while coffee ground emesis isn't usually an emergency situation, coupled with an impaired airway and cold/clammy skin it is severe enough to warrant a quick transfer out. I know code status can be a factor in fast transfers to the ER, believe me I don't want to run a code with limited resources and staff - but rule of thumb for me is DNR does not mean do not treat so when in doubt send them out! I work LTC NOC shift myself and I sympathize, it can suck to be the person responsible for making those decisions . Just curious, what did the diagnoses end up being for these two?