Monitor for Brain Injuries
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The Importance of Monitoring for Brain Injuries When Residents Fall

Approximately one quarter of fall-related traumatic brain injuries in older adults occur in long-term care facilities. According to a study by Stephen Robinovich and colleagues at the Simon Fraser University in Vancouver, British Columbia, falls from standing height or lower are the cause of more than 60 percent of hospital admissions for traumatic brain injury in adults older than 65 years. Traumatic brain injury accounts for 32 percent of hospitalizations and more than 50 percent of deaths from falls in older adults.

Unfortunately, the incidence and age-adjusted rate of fall-related traumatic brain injury is increasing, especially among people older than 80 years. Researchers found that head impact occurred in over one in three resident falls in the nursing homes they studied. Most seniors hit their heads on hard flooring, a wall or furniture. It is important to note that any fall from standing height has sufficient energy to cause brain injury if direct impact occurs between the head and a rigid surface.

Sometimes the fall can happen so quickly that a resident may not realize they struck their head, especially those suffering from dementia. When asked by the nurse if they hit their head, they will often deny it, which is especially troublesome when there are no visible signs of injury and the fall was unwitnessed. If the nurse merely accepts the resident's response without providing a series of cautionary neurological assessments, he or she may be putting that resident at risk for further injury, as well as increasing the likelihood for a lawsuit. It will be hard for that nurse to respond when the plaintiff attorney asks him or her why they took the resident's word for what happened, when it is documented throughout their record that they were chronically confused.

Brain injuries may not be obvious upon initial exam because there often is no sign of bruising or indications of trauma. An acute subdural hematoma is a collection of blood on the surface of the brain, usually caused by a major trauma to the head. It is one of the deadliest of all head injuries because bleeding fills the brain area very rapidly, compressing brain tissue, which can lead to death. Subdural hematomas also can occur after a very minor head injury, especially in the elderly. These may go unnoticed for many days or weeks and are called "chronic" subdural hematomas because blood collects slowly, over time. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In the elderly, the veins are often already stretched because of brain atrophy (shrinkage) and are more easily injured. In some cases, a subdural hematoma can occur spontaneously, without cause. The following factors increase a resident's risk for a subdural hematoma:

  • Anticoagulant medications (blood thinner, including aspirin);
  • Long term abuse of alcohol;
  • Recurrent falls;
  • Repeated head injury; and
  • Increased age.

The outlook following a subdural hematoma varies widely depending on the type and location of the head injury, the size of the blood collection and how quickly treatment is obtained. Treatment includes performing lifesaving measures, controlling symptoms, and minimizing permanent brain damage.

Healthcare providers should be prepared to seek emergency medical attention following a suspected head trauma or mental deterioration in the elderly. A crisis of the neurological system can be the most challenging to monitor and evaluate for any healthcare professional; neurological assessments can uncover nervous system dysfunction before it is too late. Therefore, it is essential that every nursing facility has policies and procedures, coordinated by the medical director, to guide and address when and how these exams should be done. Consider the following when developing your plans:

  • Have a licensed nurse perform neurological checks after all unwitnessed falls involving residents with a history of confusion and/or residents with a suspected head injury.

  • Check for signs and symptoms of head injury, which can include one or more of the following:

    • Unusual drowsiness or hard to awaken (easily or at all), mental confusion, slurred speech;

    • Nausea and forceful or repeated vomiting, stiff neck and fever;

    • Seizure activity;

    • Unequal pupils, papillary response, or accommodation;

    • Clumsy walking, stumbling, or other problems with use of extremities, areas of numbness and parasthesias;

    • Headache (mild or severe), dizziness, double vision or blind spots;

    • Increased blood pressure or a marked drop in blood pressure;

    • Decrease in pulse and/or increased and shallow respirations (these are associated with intracranial pressure); and

    • Unequal grasp/or nonexistent extremity movement (these are associated with cerebral damage).

  • Conduct an initial thorough exam at the location where the resident was found, without moving him or her. Wear gloves, when necessary, and provide as much privacy as possible.

  • Evaluate the level of consciousness and mentation of the resident. A change is usually the first clue to a deteriorating condition. Since terms, such as lethargy, are frequently used imprecisely, it is wise to descriptively document how the resident responds.

  • Check pupil reaction, blood pressure, temperature, pulse, respirations, grasp and active range of motion of all extremities. If neck or spinal injury is suspected, keep the resident still and call for emergency help.

  • Obtain orthostatic blood pressures per facility protocol. Move the resident to his or her bed only after a full assessment of actual and potential injuries is complete, and use a method that will protect the resident from any further injury.

  • Perform neurological checks according to the frequency indicated on the medical director's or attending physician's orders; a standard of 72 hours is recommended. In addition, subsequent assessments should be problem-focused, zeroing in on the parts of the nervous system affected by the resident's condition. The resident's diagnosis and the acuity of his or her condition will determine how extensive your problem-focused assessments will be and if you should conduct them more frequently.

  • Be sure to compare your findings with those of previous exams. Through comparison, you'll be able to spot changes and trends and, when necessary, intervene quickly and appropriately.

  • Immediately notify the resident's physician of any sign of deterioration in the resident's status.

The neurological assessment is a key component in the care of residents with known or suspected head trauma. It can help you detect the presence of injury and determine the types of care you need to provide. By taking these precautionary measures, you can protect your residents and facility.

Articles for research retrieved September 17, 2014 from:

http://www.cmaj.ca/content/early/2013/10/07/cmaj.130498

http://www.nlm.nih.gov/medlineplus/ency/article/000713.htm

http://www.modernmedicine.com/modern-medicine/news/neurological-assessment-refresher?page=full


 
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