A Fall on Warfarin: The First Two Minutes
At 6:40 a.m. you hear a thud and find Mrs. Whitfield, 84, on the floor beside her bed, lying on her right side. She takes warfarin for atrial fibrillation. She is awake but confused about where she is, and there is a 3 cm area of swelling with a small abrasion above her right eyebrow. Her call light lies on the floor beside her. She says, 'I just needed the bathroom. I'm fine - help me up.' Her bed is in the low position but the brakes are not set. The hallway is empty; the nurse is at the far end of the unit and the nearest call station is across the hall. She tries to push herself up onto her elbow.
1. List your actions in order for the first two minutes, and explain why each one comes when it does.
Read the worked answer
Order matters because of the anticoagulant.
- Do not let her get up and do not pull her up. She hit her head, she is on warfarin, and she is confused - standing her could worsen a bleed or cause a second fall.
- Stay with her and press the call light or call out for help. Never leave a resident who may have hit her head.
- Note the time and how you found her - position, what she was doing, what she said. This is the first thing the nurse will ask and it cannot be reconstructed later.
- Check responsiveness, breathing, and whether she can move arms and legs. Ask her name, the day, where she is; ask about pain in the hip, back, and neck.
- Cover the abrasion with a clean dry dressing - gentle pressure, no probing.
- Keep her warm and still until the nurse arrives; do not straighten her limbs or roll her unless she is vomiting or you must.
- When the nurse arrives, report the head strike, the warfarin, the confusion, the time, and the swelling, and stay to help with vital signs and a neuro check.
Reasoning: with a normal resident a bumped head is a minor event. On warfarin it is a possible intracranial bleed, so the priority flips from 'get them up and back to bed' to 'keep them still and get the nurse.'
2. Why does the head strike change the urgency, and what specifically will you watch for over the next 24-48 hours?
Read the worked answer
Why it matters: warfarin slows clotting. A blow to the head can bleed slowly inside the skull with no visible wound, and symptoms can appear hours later. The small forehead abrasion tells you the head hit something - that is the finding that triggers the protocol.
Watch for and report immediately:
- Any drop in alertness, new drowsiness, difficulty waking, or confusion worse than baseline
- Unequal or sluggish pupils
- New headache that worsens, or vomiting
- Slurred speech, facial droop, new weakness or numbness on one side
- Change in gait, balance, or one-sided clumsiness
- Clear fluid or blood from the nose or ears
- Seizure activity
Also monitor: vital signs and neuro checks on the schedule the nurse sets, the swelling site for growth, urine and stool for bleeding, and complaints of pain.
Delayed bleeding is the trap: a resident who is 'totally fine' at 7 a.m. can deteriorate at 2 p.m. Document the time of each check, not just the results.
3. She is now insistent, swinging her legs and trying to stand. What is your response, and what do you document?
Read the worked answer
Keep her safe without restraining her.
- Position yourself at her side and use your body to block the stand, at hip and shoulder level, without grabbing or holding her down. Physical holds by a CNA beyond immediate protection can be a restraint.
- Use short, calm redirection: 'Mrs. Whitfield, the nurse is coming to you right now. Let's keep your head still until she gets here.' Repeat, don't debate.
- If she is on the floor and determined to get up, get help before attempting any lift. Two staff, mechanical lift per policy - never a one-person bear hug.
- Raise the head of the bed only after she is safely back and the nurse has assessed her.
Documentation - objective and specific:
- Time found, position, what she said ('I'm fine - help me up'), the head strike, the swelling and abrasion, and the time the nurse was notified and arrived
- Neuro checks and vital signs with times
- Her attempts to stand and exactly what you did to keep her safe
- Who was notified (nurse, provider), and the family if the nurse directs
- The unsafe equipment: brakes not set, call light on the floor
Avoid: 'resident was combative,' 'fall - no injury' (you cannot rule out injury), and any speculation about why she fell.