When a client has a head strike - post fall, you may be alone until medical support arrives, and the CCM or Paramedic may ask you to check the person's responses against the Glascow Coma Scale - GCS.
You are to monitor the neurological signs described in the GCS every 30 minutes until the results are within normal limits, then continue hourly for the next four hours, then two-hourly until 24 hours of observation has been reached. Record each GCS result in a new shift note.
Support Workers doing the monitoring should also be on the lookout for the following signs and symptoms: change in condition; change in gait, balance, and/or transfer abilities that may indicate a new health or environmental problem; change in behavior; and distress or post-fall injuries.
As per your First Aid training, you can ask the person a series of questions and observe their responses to your requests for them to open their eyes, speak or move a finger or limb, see image below.
Gill, M., Windemuth, R., Steele, R., & Greene, S. M. (2005). A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Annals of Emergency Medicine, 45(1), 37-42. doi:10.1016/j.annemergmed.2004.07.429
