Don't miss underlying reason for elder's fall

Perform a functional assessment

Fractures were the most common injury (41%) of more than 2 million elders coming to community EDs in 2006 because of fall injuries, says a new report from the Agency for Healthcare Research and Quality (AHRQ).1

William Spector, PhD, one of the report's authors and a health services researcher for AHRQ, warns that your elderly patient probably has a complex medical history with many comorbidities, functional status limitations, and multiple medications. "The concern is that the elderly will get a cursory assessment and implications for caregiving will not dealt with," he says. For this reason, Spector says you should find out this information:

What services is your patient receiving?

"A fall injury may not only affect the patient, but the consequences may affect the helping network and social network they have," says Spector. "Your assessment needs to include a functional and social assessment, as well as a medical assessment."

What medications is the patient taking?

"If there are additional meds, or adjustments that need to be made with meds, there are likely to be polypharmacy issues," says Spector. "Know exactly what they are taking and what complications could arise."

What caused the fall?

"There may be underlying medical problems or environmental issues that caused the fall," says Spector.

Laura Hoban, RN, ED nurse at Scripps Mercy Hospital in San Diego, asks, "Was it a mechanical fall, or did they get dizzy or have another medical concern prior to their fall? It's very important to listen to the patient as well, as the family, to get all of the information about the fall. We may get the full story in bits and pieces."

A patient with hip pain might tell you that he or she took his or her insulin, then didn't get a chance to eat and felt dizzy. Or it might be that your patient doesn't remember what happened. "Then, you need to be concerned that they had a loss of consciousness," she says.

Look for abrasions, bruising, or deformities, even if your patient doesn't report pain, Hoban says. "Assess their ability to walk," she says. "Oftentimes, that is when they'll notice the pain, which then can be explored more."

Hoban cared for a 90-year old female who reported significant hip pain when nurses attempted to ambulate her. "After X-rays were completed and no fracture was found, it was determined that she still needed to be hospitalized because of her inability to walk due to pain," she recalls. "She was relieved, as she didn't know how she was going to care for herself."

At first, the only complaint of an elderly man seen in Oakwood Hospital and Medical Center's ED was severe pain in his left hip due to a slip and fall. However, the ED nurse's assessment revealed a significantly shortened and externally rotated left leg, which indicated a hip fracture.

"Upon further assessment, the nursing staff noted multiple bruises over the chest wall at various stages of healing," says Lori Dowell, RN, BSN, clinical educator for the ED at Oakwood Hospital and Medical Center in Dearborn, MI. "When questioned, the patient admitted to having frequent episodes of verbal and physical abuse from his at-home caregiver. The nurses were able to effectively provide for his physical and emotional needs, while addressing his need for protection against harm."

Reference

  1. Owens PL, Russo CA, Spector W, et al. Emergency department visits for injurious falls among the elderly, 2006. HCUP Statistical Brief, No. 80. October 2009. Agency for Healthcare Research and Quality; Rockville, MD.

Clinical Tip

Ask this question about elder's fall

When elderly patients report fall injuries, ask them what they were doing prior to falling.

"You may learn that it was 5 p.m. in the evening and they were not dressed for the day," says Laura Hoban, RN, an ED nurse at Scripps Mercy Hospital in San Diego. "This gives you much-needed information about their situation at home, their ability to care for themselves, and whether they have easy access to help."


Elder with fracture? Take these steps

If an elderly patient reports a fall injury, your first priority is to ensure that the patient maintains an open airway and shows signs of adequate breathing and circulation, says Lori Dowell, RN, BSN, clinical educator for the ED at Oakwood Hospital and Medical Center in Dearborn, MI.

"Supplemental oxygen may be needed," she says. "Cervical spine immobilization may be required through the use of a cervical collar and backboard."

Treatment of an elderly patient's fracture might begin with proper splinting or immobilization above and below the deformity, says Barb Smith, RN, BSN, MSA, CEN, trauma program manager at Botsford Hospital in Farmington Hills, MI. "Make sure to check distal pulses before and after the application, to ensure there is no neurovascular compromise," she says. Next, follow these steps:

  1. Apply ice to control pain and decrease swelling.
  2. Cover open wounds with a sterile dressing.
  3. Anticipate the need for antibiotics.
  4. Administer pain medications. "Remember that the elderly may be more sensitive to narcotics," says Smith. "Close monitoring is important."