A nurse hears a loud thud and rushes into the room of a client receiving a continuous intravenous heparin infusion for a pulmonary embolism. The nurse finds the client lying on the floor, confused, attempting to stand, and bleeding profusely from a laceration on the temporal area of the head. Arrange the following nursing actions in the priority order they should be performed.
- 1Verbally instruct the client to remain completely still on the floor.
- 2Call out for immediate emergency assistance from nearby staff.
- 3Don clean gloves and apply direct, firm pressure to the temporal laceration.
- 4Delegate an arriving colleague to pause the continuous intravenous heparin infusion.
- 5Perform a focused neurological assessment, including the Glasgow Coma Scale.
- 6Notify the primary healthcare provider of the event and clinical findings.
Answer
The correct sequence is: Instruct the client to remain still, call for assistance, apply direct pressure to the wound, delegate pausing the heparin, perform a neurological assessment, and finally notify the healthcare provider.
In emergency scenarios involving falls and trauma, the nurse must prioritize immediate threats to life based on safety principles and the ABCs (Airway, Breathing, Circulation). The very first priority is to stop the client from standing to prevent a secondary fall or spinal injury. The nurse must then immediately call for help, as managing a bleeding, confused client requires multiple personnel. Next, the nurse addresses the severe circulatory threat by applying direct pressure to the wound, which is critically urgent given the continuous heparin infusion. Once help arrives, the nurse delegates stopping the heparin to prevent further hemorrhagic complications. Only after these immediate physical and circulatory threats are stabilized should the nurse conduct a thorough neurological assessment. Finally, the healthcare provider is contacted with a complete clinical picture to obtain emergency orders, such as a STAT CT scan.
Step-by-Step Solution
Key Concept
Emergency prioritization and injury prevention for falls in clients receiving systemic anticoagulation.