Final answer:
The nurse's priority after a patient fall is to ensure the patient's safety, assess for injuries, and then address the root cause by identifying factors that led to the fall. Counseling personnel or removing fall risk signs are not immediate priorities. Accurate documentation and re-evaluation of fall prevention measures are crucial steps in post-fall care.
Step-by-step explanation:
When a patient falls in a healthcare setting, the first priority of the nurse is to ensure the patient's immediate safety and to assess for any injuries sustained during the fall. This involves performing a physical assessment and providing necessary medical care. After the immediate needs are addressed, the nurse should follow institutional protocols which often include reviewing and analyzing the circumstances that led to the fall. This process is important to identify factors that may have interfered with goal achievement and to determine necessary preventative measures to avoid future falls.
These actions could include evaluating the fall risk assessment protocols, reviewing the completeness and appropriateness of any preventive measures that were in place (such as bed alarms or adequate lighting), and ensuring that all items, including equipment, are functioning properly. It is essential also to document all aspects of the fall and the post-fall assessment accurately. This might involve conferring with other healthcare team members to gather multiple perspectives on the incident, but ultimately the nurse responsible for the patient at the time of the fall should complete the documentation.
It is not appropriate to counsel assistive personnel immediately or to remove fall risk signs simply because the patient has fallen; instead, re-evaluating the patient's fall risk status and possibly even increasing fall prevention measures may be necessary. Collaboration with more experienced nurses, like the charge nurse, can be beneficial in determining the best course of action moving forward to ensure patient safety.