Place the nursing actions in order after finding an anticoag… | MyMerci
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Accident/Error/Injury Prevention

Place the nursing actions in order after finding an anticoagulated older adult on the floor after an unwitnessed fall.

Ordered Response

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Remain with the client, stop unassisted movement, call for help, and address any immediate environmental danger
Notify the responsible clinician or emergency team promptly and prepare for indicated imaging, treatment, and enhanced observation
Assess responsiveness, airway, breathing, circulation, cervical-spine risk, and obvious bleeding before moving the client
Document the objective findings and response, complete required reporting, and revise the individualized fall-prevention plan
Obtain baseline vital signs, neurologic status and Glasgow Coma Scale, glucose when indicated, pain, injuries, and the medication history
Explanation
Stay with the client and obtain help before attempting to lift. Assess ABCs, possible cervical injury, and bleeding first, then establish neurologic and vital-sign baselines while recognizing the added intracranial-bleeding risk from apixaban. Notify the clinician or emergency team promptly for further evaluation and monitoring. Document and revise prevention after urgent care is underway.
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For study reference only. Always follow current clinical guidelines and your institution’s protocols.

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