When the nurse finds that a patient has fallen the first intervention should be to?

Chapter 20: FallsMULTIPLE CHOICE1.The nurse caring for a patient with ataxia would recommend that the family, in preparationfor discharge home:1.remove all scatter rugs from the home.2.rearrange the bedroom furniture.3.arrange for someone to stay with the patient 24 hours a day.4.purchase oversized shoes so that they are easy to get on.ANS:1Scatter rugs can slip and cause a patient to fall.

2.When the nurse finds that a patient has fallen, the first intervention should be to:

3.Discharge planning for a patient who lives alone and is at high risk for falling should in-clude telling the patient:

4.The nurse explains that the older adults account for a large percentage of the total deathsresulting from falls. This percentage is:

5.The nurse is caring for an older adult patient who has undergone a total hip replacement. Toreduce the risk of further injury, the nurse would:1.leave all the lights in the room on at night.2.leave the side rails down at all times so that the patient can get to the bathroomquickly.3.keep the call bell and other frequently used items in easy reach.4.keep the bed in the high position so that the patient will not be tempted to get outof bed alone.ANS:3Keeping the call bell and other frequently used items within easy reach will prevent the pa-tient from having to reach, which increases the risk for falling.

6.The nurse is talking to the family of a patient who has fallen several times. She knows thather teaching should be aimed toward the most important intervention for falls, which is:

7.When caring for a patient who requires wrist restraints, the nurse should be sure to removeand release the restraints once every:

Today’s discussion involves what a nurse should do if a patient falls while in their care. We will be talking about the four steps that nurses should take in response to a fall. Our discussion will also focus on what happens if a nurse does not follow the correct procedure. Patient care and the mitigation of patient injuries are the main purpose of this blog. Let’s get into the four steps in response to a fall.

Not only can falling accidents lead to increased hospital costs and lengths of stay for patients, but these accidents can also lead to reduced mobility, loss of function, and additional falls in patients. When a patient does fall, nurses need to respond quickly and safely. The American Journal of Nursing provides four steps that nurses should take in response to a fall to both keep the patient safe and help protect the nurse’s license in case of complications.  These steps are assessment, notification and communication, monitoring and reassessment, and documentation. 

Four Steps in Response to a Fall

The first thing a nurse should do after a patient falls is to assess the patient. Start by asking the patient why they think the fall occurred and assess associated symptoms, and then check the patient’s vital signs, cranial nerve, signs of skin trauma, consciousness and cognitive changes, and any other pain or points of tenderness that could have resulted from the fall. It is important that you don’t assume that no injury has occurred or move the patient before assessing them. 

The second step is to notify your patient’s primary care provider and anyone else that your facility requires you to notify. For example, some facilities also require you to notify a family member. Making sure that you inform all staff in the patient’s unit is also an important part of preventing a second fall. 

The next step a nurse should take is to monitor and reassess your patient. For at least 72 hours after your patient’s fall, make sure you perform frequent neurologic and vital sign checks to make sure your patient does not have any additional injuries from their fall.

The fourth step is documentation. This step is crucial in protecting your license. It helps ensure that appropriate nursing care and medical attention are given to your patient. Make sure to follow your facility’s policies and procedures for documenting a fall, and include all observations, patient statements, assessments, notifications, interventions, and evaluations. Additionally, many facilities require you to make an additional incident report outside of your patient’s records, and this report should include patient history, how the fall occurred, assessment, diagnosis, intervention, and outcome. If you are unsure what your facility’s procedures are, make sure you talk to your Nurse Manager or supervisor.

What Happens If a Nurse Does Not Follow Correct Procedure After a Patient Falls?

Failing to properly treat and document a patient after a fall can result in disciplinary actions with the NC Board of Nursing taken against your license. Neglecting a patient by failing to properly treat them and failing to maintain an accurate patient medical record by not correctly documenting the patient’s fall are two of the most common reasons that nurses can be reported to the Board. Occasionally, a nurse might not perform a complete assessment after a patient falls because it looks like it was only a minor fall or the patient does not seem to be injured. Other times, a nurse might not provide a full written description of the external circumstances surrounding a patient’s fall because the nurse is busy or has other patients to see.

The NCBON warns nurses about the serious risks of “practice drift,” meaning any shortcuts or rule-bending that a nurse might take in order to accomplish an immediate goal or promote efficiency. Although these might seem like harmless choices, it is important to make sure you follow proper procedures after a patient falls to keep them safe and to avoid serious disciplinary actions against your nursing license.

Nothing in this blog post is legal advice or establishes the attorney-client relationship.  This is for informational purposes only.  If you’d like to learn more about professional licensing issues in North Carolina check out our site at www.northstatelawfirm.com or our YouTube site here.  919-521-8810 is the direct line to North State Law.

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