Ready Hands · Seoyeon Kim
Chapter 11: Falls, Head Injuries and Broken Bones
What Can Happen
A care worker arrives for a morning visit and finds the woman she supports sitting on the bathroom floor. The woman says that she slipped in the night, that she is fine, and that she only needs a hand to get up. Her voice is calm, but there is a bruise on her forehead, and she cannot say how long she has been on the floor. The care worker feels the urge to lift her at once, and she has to decide whether that is safe.
Falls are among the most common emergencies in care, at home, in care homes and outside on uneven pavements and kerbs. This chapter explains what to do after a fall, how to recognise the signs that a head injury needs emergency help, and how to support a possible broken bone. It also explains how to care for a possible neck or back injury and for a sprain, and why every fall is reported, even when the person seems unhurt. As in every chapter, follow your workplace's emergency procedures and report what happened.
Step by Step: After a Fall
Step 1. Stay calm and do not rush to lift the person. Lifting too soon can make an injury worse, and lifting a person by hand can injure you as well. Tell the person that you are there and that you will help, and ask them to stay still for a moment while you check. Kneel or crouch at the person's level so that they can see your face and hear you clearly.
Step 2. Check for danger to you and to the person, such as a wet floor, broken glass or a heater, or, outside, traffic and a hot road surface. Remove the danger if you can do it safely. Move the person only if staying where they are puts them in danger, for example in a road with traffic or near a fire. A person lying beside a kerb may be hard for drivers to see; if you cannot move the person, make the place visible and ask others to warn traffic, as Chapter 9 explains.
Step 3. Check whether the person responds and whether they are breathing normally, as described in Chapter 3. If the person does not respond, shout for help and call the emergency number, or ask someone else to call. If the person is unresponsive but breathing normally, keep the airway open and read the guidance on neck injuries later in this chapter before you turn the person. If the person is not breathing normally, start CPR as described in Chapter 4.
Step 4. If the person is awake, ask where it hurts, what happened and whether they hit their head. Ask whether they felt dizzy, faint, short of breath or unwell before the fall, because a fall can be the first sign of an illness, of heat exhaustion on a hot day or of a drop in blood sugar. Listen carefully, and remember the answers for the paramedics and for your report.
Step 5. Look gently for injuries without moving the person. Look for bleeding, a bump or a wound on the head, swelling, and an arm or a leg that is bent in an unusual shape. A leg that looks shorter than the other, with the foot turned outward, can be a sign of a broken hip, which is a common injury after a fall in older people. Do not ask the person to test a painful arm or leg by moving it.
Step 6. Call the emergency number if the person hit their head and shows any of the worrying signs described in the next section, if you think a bone may be broken, if the person cannot get up, or if the person has been on the floor for a long time. Call also if the fall happened outside in the heat, because a person lying on hot ground or in the sun can quickly develop heat illness. Follow the operator's instructions, and tell your workplace as your procedure says.
Step 7. Keep the person warm and comfortable while you wait for help. Put a blanket over them, and put a cushion under the head only if the neck is not painful, because a person who stays on a cold floor can lose heat quickly. Outside on a hot day, give shade, and keep the person's skin off a hot surface if you can do so without moving an injured part. Waiting on the floor can be frightening and embarrassing, so explain what is happening, and protect the person's dignity by covering them and keeping others away.
Step 8. If the person is not hurt and wants to get up, follow your workplace's procedure for getting up safely after a fall. Often this means guiding the person to get up slowly by themselves, in stages, with a stable chair to lean on, or using lifting equipment that you have been trained to use. Never lift a person from the floor by hand on your own. Afterwards, watch the person closely for the rest of your visit, and report the fall.
Signs After a Head Injury
A blow to the head can injure the brain even when the outside of the head shows only a small bump, or nothing at all. For a person who is awake and talking normally after a minor bump, a cold pack wrapped in a cloth can be held gently against the bump to ease pain and swelling. Never put ice directly on the skin. At the same time, watch the person carefully, because some signs of a serious injury appear only later.
Call the emergency number at once if the person, after a head injury, is drowsy or hard to wake, has been unconscious even for a short time, vomits, is confused or cannot remember what happened, or has a severe headache or a headache that gets worse. Call also for unequal pupils, which means that the black centre of one eye is larger than the other, for clear fluid or blood coming from the nose or ears, or for a seizure. Weakness or numbness on one side of the body, slurred speech, and trouble with seeing or with balance are also reasons to call.
In older people, bleeding inside the head can develop slowly, and the signs can appear hours or even days after a fall that seemed minor. This is more likely in people whose care plan says that they bleed easily. For this reason, many workplaces have a procedure for watching a person closely after any head injury, and for telling the nurse, the doctor and the family. Follow that procedure, and write down when you notice any change and what it was. If the person comes back from hospital after a head injury, follow the instructions given there about what to watch for, and keep them where the whole team can read them.
Some people cannot tell you how they feel, for example a person living with dementia or a person who has lost speech after a stroke. For them, a change in behaviour may be the only sign: more sleepiness than usual, new confusion, restlessness, refusing food, or not using one arm. You often know the person better than anyone else, so trust what you notice and report it. A change that worries you is a good reason to call, and nobody will blame you for calling.
If you were not there when the person fell, and you find them on the floor or with a new bruise on the head, give first aid as if they had hit their head. Ask the person, and anyone nearby, what happened, but do not rely on the answer if the person seems confused. Tell the operator or the nurse that nobody saw the fall, because this changes how carefully the person will be checked.
Step by Step: Supporting a Suspected Broken Bone
Step 1. Suspect a broken bone when there is pain, swelling, bruising or an unusual shape, or when the person cannot move the injured part or put weight on it, especially after a fall in an older person. You do not need to know for sure. If you are not certain whether a bone is broken or the injury is only a sprain, give first aid as if the bone were broken.
Step 2. Ask the person to keep still, and call the emergency number, or ask someone else to call. Tell the operator how the person fell, where the pain is and what you see. A possible broken hip, thigh or pelvis in an older person is a serious injury, and the person should not be moved except by the ambulance crew.
Step 3. Support the injured part in the position in which you found it. Do not try to straighten it or push a bone back into place. Place rolled blankets, towels, clothing or cushions along both sides of the injured part, or hold it steady with your hands, so that it cannot move. The aim is to keep the joints above and below the injury still as well.
Step 4. If an injured arm is not too painful to move, the person may want to hold it against the body with the other hand; let the person find the most comfortable position. If you have learned in a course how to support an arm with a sling, you may use one. Never force a sling or any support onto an arm or a leg that hurts more when it is moved.
Step 5. If a bone has broken through the skin, or if there is a wound over the injury, cover it with a clean dressing and control bleeding by pressing around the wound, not on the bone. Do not push anything back into the wound. Watch for signs of shock, as described in Chapter 10, because a broken bone, especially in the hip or thigh, can cause heavy bleeding inside the body.
Step 6. Do not give the person anything to eat or drink, because they may need treatment in hospital. Keep the person warm, and check the hand or the foot below the injury for coldness, numbness or a change in colour. Stay with the person, reassure them, and tell the paramedics what you have seen and when the fall happened. If the person has a list of their medicines and a care plan at home, have them ready for the paramedics, as your workplace keeps them.
Neck and Back Injuries, Sprains and Reporting
An injury to the neck or back is possible after a fall from a height, a fall down stairs, a fall from a wheelchair, a road accident or a hard blow to the head. Suspect it if the person has pain in the neck or back, tingling, numbness or weakness in the arms or legs, or if the person is unresponsive after such a fall. Ask the person to keep still and not to move the head, call the emergency number, and keep the person still yourself as your course teaches. Many courses teach kneeling behind the person's head and holding it steady with one hand on each side, in the position in which you found it.
Do not move a person with a possible neck or back injury unless they are in danger, for example from traffic or fire. Breathing always comes first: if the person is unresponsive and not breathing normally, open the airway and start CPR as courses teach, even if you fear a neck injury. If the person is breathing but vomits or cannot keep the airway clear, turn the person carefully onto the side, keeping the head, neck and body in line, with help from others if possible, as your course teaches.
A sprain is an injury to the tough tissue that holds a joint together, often at the ankle or the wrist after a twist on an uneven pavement or a kerb. Help the person rest the joint and sit or lie comfortably. Hold a cold pack wrapped in a cloth against the joint for the time your course teaches, never with ice directly on the skin, and support the joint in a comfortable position. If the person cannot put weight on the joint, if the pain is severe, or if you are not sure whether a bone is broken, treat it as a broken bone and get medical help. Even a mild sprain should be checked by a doctor or a nurse if the pain or swelling has not eased by the next day.
Report every fall, even when the person seems unhurt and asks you not to tell anyone. A fall can be a sign of illness, of dehydration on a hot day, of a change in the person's health, or of a danger in the home that needs fixing. Record when and where the fall happened, what the person said, what you saw and what you did, and inform the nurse, the supervisor and the family as your workplace's procedure says. Your report helps the whole team to prevent the next fall.
A fall can also change how a person feels about moving. Many people become afraid of falling again, and they may move less, which makes them weaker and more likely to fall. Speak kindly about what happened, avoid blaming the person or yourself, and tell the team if the person seems frightened, so that the care plan can include support for walking and moving safely again.
Things to Check
Check the floors in the home or the room for things that can cause a fall, such as loose rugs, wet patches, cables and clutter. Removing one danger can prevent a serious injury.
Check that the person's walking aid, wheelchair brakes and footwear are in good condition before every outing. Worn soles, loose straps and brakes that slip are common causes of falls on pavements and kerbs.
Check the route of an outing for uneven pavements, high kerbs, steps and places without shade. A smoother, cooler route makes a fall less likely and makes help easier to reach if one happens.
Check that you know your workplace's procedure for getting a person up after a fall, and where the lifting equipment is kept. Ask for training if nobody has shown you how to use it.
Check whether the person has an alarm or a call button, and that they wear it and know how to use it. A person who can call for help quickly does not lie on the floor for long.
Check the person's care plan for anything that makes a fall more serious, such as fragile bones or a note that the person bleeds easily. This tells you when to watch more closely after a bump to the head.
Check that the lighting is good on the way to the bathroom and at the door, especially at night. Many falls happen when a person gets up in the dark.
Check that you know how your workplace wants falls recorded and reported, and to whom. A clear record of every fall, even a small one, helps the team to see patterns and to act on them.