Fall with head injury / suspected head injury (inpatient)

1. Fall with head injury / suspected head injury (inpatient) Head injury: ‘any trauma to the head, other than superficial injuries to the face’ • Doctors’ responsibilities – Assess patient with suspected head injury & perform neurological examination • Nurses’ responsibilities – Monitor level of consciousness for potential deterioration • Neurological observations MUST be commenced on any patient following a fall if any of the following signs/symptoms or indications apply • Witnessed head injury • External bruising, swelling or laceration to the head • New onset of symptoms suggestive of brain injury • Vomiting, headache, altered consciousness, dizziness • On anticoagulation therapy (full anticoagulant, not DVT prophylaxis) • Pain or tenderness on head Patient must be commenced on a neuro observation chart & have neurological observations recorded half-hourly (overnight the patient must be woken up) until GCS (Glasgow Coma Scale) is 15 GCS 15 NO YES ½ hourly neuro obs for 2 hours Review by medic within 30 minutes Continue ½ hourly neuro obs 1 hourly neuro obs For 4 hours If GCS drops by 2 points Review by medic within 30 minutes Recommence ½hourly neuro obs 2 hourly neuro obs for 6 hours Review Note Patients with cognitive decline or dementia may not present in the same way As well as the above, distinct changes in usual behaviour / level of agitation, restlessness or listlessness will require immediate review All other post fall care should continue in line with falls policy