Care of a client who has fallen or one who has been found on the floor should include the following steps:
Assess the situation and approach if safe to do so
Undertake a swift assessment of the condition
of the client
Are signs of life present?
Is the client conscious?
How does the client appear: pale, clammy, cyanosed?
Are they breathing?
Does the client have a pulse?
Make the client comfortable
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
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
client and keep them informed about what is happening
A hoist (sollevatore meccanico) 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
Keep the patient informed and reassure continually throughout the procedure
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
Inform Senior Nurse, complete untoward incident/accident form in keeping with local policy
Update nursing care plan and movement and handling assessments