Care of an individual who has fallen

Care of a client who has fallen or one who has been found on the floor should include the following steps:

Procedure	Rationale
Assess the situation and approach if safe to do so	To ensure personal safety
Undertake a swift assessment of the condition of the client	To assess for life-threatening problems which require urgent medical/nursing attention
Are signs of life present?	Is this a simple fall, slip, trip or faint; or has the patient suffered a life-threatening event, e.g. cardiac arrest, resulting in their being found on the floor
• Is the client conscious? • How does the client appear: pale, clammy, cyanosed? • Are they breathing? • Does the client have a pulse?	If life signs are not present, cardiopulmonary resuscitation should be commenced
Make the client comfortable by: • Placing a pillow under their head if appropriate. If injury to the neck is suspected this should not be undertaken • Maintaining the client’s dignity	To keep the client as comfortable as possible until it is safe to move them, whilst maintaining their safety and preventing them from further harm
Get help, both medical and nursing	The client should have a medical assessment performed prior to attempting to move them from the floor to ensure that they are safe to be moved without causing further harm or injury. The help of both medical and nursing staff will ensure that identified injuries can be treated promptly, whilst enabling a member of staff to remain with the client at all times. To move a client from the floor safely requires teamwork and cannot safely be performed alone
Following assessment treat injuries needing urgent attention, where the client has fallen, before attempting to move them	To prevent further injury or discomfort
Reassure the client and keep them informed about what is happening	To reduce anxiety and increase the likelihood of co-operation
A hoist should be used to get the client from the floor, unless they can either do this for themselves or the use of a hoist is contra-indicated	It is unsafe to lift a client from the floor manually. A hoist or stretcher hoist should always be used if at all possible
Keep the patient informed and reassure continually throughout the procedure	To reduce anxiety and increase the likelihood of co-operation
If the client is attempting to get himself or herself up from the floor and it is considered safe for them to do so, they should be encouraged to roll so that they can position themselves on their hands and knees	To encourage independence and return of confidence
It may then be useful to place a chair for them to lean on, before attempting to stand	To reduce the potential for postural hypotension by enabling a staged return to an upright position
Ensure before allowing them to undertake this manoeuvre that the floor is not slippery and that they are wearing appropriate footwear	To maintain a safe environment
Assess the situation and move the client using appropriate, effective manoeuvres	To enable the client to be moved safely and effectively to an area where further medical/nursing assessment and treatment can be undertaken
Promote client comfort	Following movement it is important to ensure that the client feels comfortable and safe to restore confidence
Reassess for injuries	Reassessment of injuries should be undertaken once the client is comfortable and in a safe area to identify any further injuries, which may not have been identified immediately after the initial incident
Continue to monitor the client	To ensure early detection of any changes in condition
Inform Senior Nurse, complete untoward incident/accident form in keeping with local policy	To meet health and safety legislation
Update nursing care plan and movement and handling assessments	To ensure consistency in care delivery
Inform next of kin	To aid good communications and acknowledge duty of care