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 examinationNurses’ 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 injuryVomiting, 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

NotePatients with cognitive decline or dementia may not present in the same wayAs 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

GCS 15

NO YES

Review by medic within 30 minutes

Continue½ hourlyneuro obs

½ hourly neuro obsfor 2 hours

1 hourly neuro obsFor 4 hours

2 hourly neuro obsfor 6 hours

Review

If GCS drops by 2 pointsReview by medic within 30 minutesRecommence ½ hourlyneuro obs