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Background: This protocol explains how to assess and follow injury risk in a patient who has fallen.
Reference: Adapted from the South Australia Health Fall Prevention Toolkit. Available at: www.sahealth.sa.gov.au/wps/wcm/connect/5a7adb80464f6640a604fe2e504170d4/Post+fall+management+protocol-SaQ-20110330.pdf?MOD=AJPERES&CACHEID=5a7adb80464f6640a604fe2e504170d4.
How to use this tool: Staff nurses and physicians should follow this protocol, in combination with clinical judgment, with patients who have just fallen. Training on the Glasgow Coma Scale is available at: www.nursingtimes.net/Binaries/0-4-1/4-1735373.pdf. (Full citation: Jevon P. Neurological assessment part 4—Glasgow Coma Scale 2. Nurs Times 2008;104(30):24-5.) This training includes graphics demonstrating various aspects of the scale.
Postfall Assessment, Clinical Review
Note: There is increased risk of intracranial hemorrhage in patients with advanced age; on anticoagulant and/or antiplatelet therapy; and known coagulopathy, including those with alcoholism.
In addition, there may be late manifestations of head injury after 24 hours.
| Does not hit head | Hits head or has unwitnessed fall |
|---|---|
Proceed to:
Observations:
|
Proceed to:
Observations:
|
Important Communications
- In the medical record, document the incident, outcome, and initial and ongoing observations, and update fall risk assessment and care plan.
- Notify the treating medical provider at the time of the incident, and schedule an interdisciplinary review of the patient's care.
- At handover, inform all clinical team members about the incident, any changes to the care plan, and possible investigation process.
- Notify family in accordance with your hospital's policy.
Glasgow Coma Scale
The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories. For adults, the scores follow:
Activity Score
| Activity | Score |
|---|---|
| Eye opening | |
| None | 1 = Even to supraorbital pressure |
| To pain | 2 = Pain from sternum/limb/supraorbital pressure |
| To speech | 3 = Nonspecific response, not necessarily to command |
| Spontaneous | 4 = Eyes open, not necessarily aware |
| Motor response | |
| None | 1 = To any pain; limbs remain flaccid |
| Extension | 2 = Shoulder adducted and shoulder and forearm rotated internally |
| Flexor response | 3 = Withdrawal response or assumption of hemiplegic posture |
| Withdrawal | 4 = Arm withdraws to pain, shoulder abducts |
| Localizes pain | 5 = Arm attempts to remove supraorbital/chest pressure |
| Obeys commands | 6 = Follows simple commands |
| Verbal response | |
| None | 1 = No verbalization of any type |
| Incomprehensible | 2 = Moans/groans, no speech |
| Inappropriate | 3 = Intelligible, no sustained sentences |
| Confused | 4 = Converses but confused, disoriented |
| Oriented | 5 = Converses and oriented |
TOTAL (3–15): _______
Reference
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81-4.
