3. Discuss the initial nursing interventions when the nurse enters Mr. O’Brien’s room and finds him lying on the floor.
The nursing interventions after a fall is important because the fall may have caused injury to the patient. Patients in the older population who have fallen have a 30%-40% chance to fall again so it is important for the nurse to evaluate what caused the fall so measures can be taken to prevent this recurrence (Chapter 2. Fall response, 2014). The nurse should assess any injuries that may have occurred such as a broken bone, head injury, abrasions, and lacerations (Jones, 2011). It is crucial that the nurse recognize the signs and symptoms of injury so prompt treatment can be initiated.
In Mr. O’Brien’s case, the first nursing intervention consist of completing a fall assessment protocol depending on facility policy. The nurse assesses the client’s position in the floor and asking the patient if pain is present. Mr. O’Brien is complaining of right hip pain and this should alert the nurse that his right hip could be injured from the fall. The nurse should assess the rest of his body for discoloration, redness, or any other painful areas that Mr. O’Brien may have. The nurse along with the healthcare team should help Mr. O’Brien off the floor into the bed following a set of vital signs including blood pressure, apical pulse, respiratory rate, oxygen saturation, and level of pain. Since the fall was unwitnessed, neurological assessments should be performed routinely for possible head injuries. The envir...
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...ure that the bed is in the lowest position and the wheels are locked, the call light is within reach and the patient understands how to use it. Assure that the patient’s personal belongings are within reach, and that the patient has non-skid socks on. If the patient was to get up without help, the non-skid socks can reduce the risk of falling. The nurse should also ask the patient if he/she needs to use the restroom before leaving (Ganz, 2013). The nurse can use a mat on the floor on each side of the bed to prevent injury if the patient was to get out of bed without assistance. The bed alarm or a personal alarm should be on and underneath the patient so if the patient were to get up, the alarm will alert the nurses (Chapter 2. Fall response, 2014). The staff should also make sure that the floor is not wet when transferring a patient. A wet floor can cause the patient
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