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Suspect a fall although an elder says otherwise?
You might need to probe further
If an elder patient denies falling, would you take the answer at face value or probe further? "What I have found in my practice over the last 15 years is that the elderly patient population does not like to complain," says Jill Hill, RN, clinical educator for emergency services at Southwest Washington Medical Center in Vancouver. "They are generally very stoic. You may have to do a bit more investigation and cajoling to get to the truth."
Elders might fear losing their independence. "The patient may think that if they tell you they 'tripped and fell again,' that their daughter will put them in a home, or if they admit, 'I hit the gas pedal instead of the brake,' that their driver's license will be taken away," says Hill.
This worry, real or unfounded, can cause elder patients to leave out details of an injury or claim there has been no injury at all, says Hill.
Falls also go undetected in elder patients due to lack of awareness in those around them. "This is much like heart attack and stroke used to be," says Hill. "You'll hear, 'I just thought mom was being goofy,' or 'Dad did tell us he has been dizzy lately, but we just told him to lie down.'"
Family and friends might believe their loved one is just having a 'senior moment' when in fact their behavior indicates a possible head injury, says Hill. "Also consider most families are spread out these days. The altered level of consciousness and bruises from a fall may not be noticed by anyone for several days," says Hill.
To improve assessment of elder fall injuries, take these steps:
Ask every patient with a complaint that indicates a possible head or brain injury whether "anything out of the ordinary" happened in the past three weeks.
What might seem like an insignificant event to the patient might tell you that a brain injury is a significant possibility that needs to be ruled out, says Hill. "With some patients, it is not necessarily what you ask, but how you ask it," she says.
If the patient appears to have an altered level of consciousness, get in touch with family or caregivers.
"You need to be assured the patient is a reliable source of information," says Hill. "The altered person in front of you may be generally sharp as a tack, according to friends or family."
Find out if the patient takes any medications that affect balance or cognitive ability.
Ask about sedatives, sleeping pills, blood pressure pills, and anti-arrhythmics, as well as alcohol use. "A little bump on the head for the average person may be nothing more than that. But if you are on a blood thinner, the ball game changes," says Hill. "Also, always ask the patient what their definition is of 'just a little cocktail in the evening.'"
For more information on assessment of elders in the ED, contact:
Don't let staff rely on previous assessment
Can you be sure that your patient's mental status or pupil size hasn't changed from the last time the off-going nurse saw her, until the moment you walked in the room?
"Always do your own neurological assessment for an elder with a fall injury. Brains can swell quickly," says Jill Hill, RN, clinical educator for emergency services at Southwest Washington Medical Center in Vancouver, WA.
Perform hourly roundings and assessments on your patients, at a minimum, Hill says. "If your gut tells you to reassess more often, go with that feeling," she says. "You cannot go wrong with more frequent assessments."
One of Hill's ED nursing interns detected fixed and dilated pupils on a patient, which led to an immediate CT and immediate departure to the OR.
"She had a 'feeling,' decided to do neuro checks every 15 minutes, picked up on the change and notified the provider immediately," says Hill. "We are the front line at the bedside. If anyone is going to be the first to notice a change in our patient's condition, it should be us."
Note subtle neuro changes in an elderly patient?
Your elder patient with a fall injury could have an undiagnosed brain injury. This is because their presenting symptoms might be masking a more subtle neurologic change.
"If an older patient falls and sustains a wrist fracture, the fact that they also hit their head may go unnoticed while the health care providers are trying to control pain and stabilize the fracture," says Karen Bergman, RN, neuroscience coordinator at Bronson Methodist Hospital in Kalamazoo, MI.
Bergman gives these recommendations:
1. Ask the patients if they hit their head, either on the ground or on another object, while falling.
"Inspection of the head may help to identify abrasions or bruising, indicating that the head did have an impact," says Bergman.
2. Perform neurologic exams to identify subtle changes in the patient's status.
"Neurologic exams in the ED should be compared to baseline neurologic status, in order to detect changes," says Bergman.
3. Be aware of interventions that are helpful or harmful to brain tissue survival.
Bergman says these three interventions are helpful for controlling secondary damage from severe traumatic brain injury:
Elevate the head of the bed, when allowed.
Maintain low normal partial pressure of carbon dioxide levels.
Provide adequate oxygenation and blood pressure support to increase brain tissue oxygen.
"Hypotension and hypoxia following traumatic brain injury are known to increase mortality," adds Bergman.
4. Establish the mechanism of injury, so that you can understand the magnitude of the impact that the brain sustained.
A fall from a standing position versus a fall from 10 feet would create different forces on the brain upon impact, says Bergman. This information alone, however, doesn't tell you if the injury is mild, moderate, or severe, she notes.
"Severity of injury to the brain is established by clinical assessment and CT findings," says Bergman. "Mechanisms of injury and medical and medication history are used to heighten awareness to potential complications." The fact that your patient is on warfarin, for instance, should increase your suspicion for intracerebral hemorrhage.