What are the signs of intracranial bleed in a geriatric patient with a history of falls, hypertension, or anticoagulant use residing in a Skilled Nursing Facility (SNF)?

Signs of Intracranial Bleed in SNF Patients: Nursing Orders

In geriatric SNF patients with falls, hypertension, or anticoagulant use, immediately assess for altered mental status, focal neurologic deficits, severe headache, nausea/vomiting, and declining level of consciousness—these are the critical signs that mandate urgent head CT and emergency transfer. 1

High-Risk Patient Profile in SNF Setting

SNF residents are at substantially elevated risk for intracranial hemorrhage due to:

• Anticoagulant use (warfarin, dabigatran, rivaroxaban, apixaban) increases intracranial bleeding risk 7-10 fold to nearly 1% per year 2, 3
• History of falls (the leading cause of trauma in 75% of geriatric patients) 1
• Hypertension (present in most geriatric patients and a major independent risk factor) 1, 3
• Antiplatelet agents (clopidogrel, aspirin) carry similar bleeding risks to anticoagulants 1, 4
• Advanced age (>74 years significantly increases mortality risk) 1

Critical Clinical Signs to Monitor

Neurological Changes (Highest Priority)

• Altered mental status or acute confusion (present in 7.4% of patients with intracranial findings) 1
• Declining level of consciousness or unresponsiveness 1
• Focal neurologic deficits (weakness, numbness, speech changes, visual disturbances) 1
• New-onset seizures 1

Associated Symptoms

• Severe or worsening headache 1
• Nausea or vomiting 1
• Impaired consciousness 1

Vital Sign Changes

• Systolic blood pressure <110 mmHg (concerning in geriatric trauma patients) 1
• Heart rate >90 bpm (lower threshold for trauma activation in elderly) 1

Critical caveat: Geriatric patients on beta-blockers may have blunted heart rate and blood pressure responses to significant bleeding, masking typical signs of deterioration 1

Immediate Nursing Actions

For ANY head trauma in anticoagulated patients:

• Obtain immediate non-contrast head CT regardless of symptom severity or mechanism (even ground-level falls require imaging) 4
• Do not wait for symptoms to develop—anticoagulated patients have 3.9% risk of significant intracranial injury vs 1.5% in non-anticoagulated patients 4

For suspected intracranial bleed:

• Discontinue anticoagulant immediately 5, 4
• Emergency transfer to acute care facility 5, 4
• Document exact time of symptom onset (critical for reversal timing) 5
• Obtain current medication list (especially anticoagulants, antiplatelets, beta-blockers, steroids) 1

Common Pitfalls to Avoid

• Failing to obtain CT imaging after ANY head trauma in anticoagulated patients, even with minor mechanisms like ground-level falls 4
• Assuming normal vital signs rule out serious bleeding in patients on beta-blockers who cannot mount appropriate tachycardia 1
• Delaying imaging while "observing" the patient—approximately 50% of anticoagulant-related intracerebral hemorrhages evolve slowly over 12-24 hours, making early detection crucial 2
• Missing subtle mental status changes in patients with baseline cognitive impairment (nearly 60% of long-term SNF residents) 1
• Underestimating risk in patients on NOACs (apixaban, rivaroxaban, dabigatran)—while lower risk than warfarin (2.6% vs 10.2%), still substantially higher than non-anticoagulated patients 4

Documentation Requirements

Document and report immediately:

• Exact time of fall or symptom onset 5, 4
• Baseline neurological status and any changes 1
• Current anticoagulation status (medication, dose, last administration time) 1, 4
• Vital signs including blood pressure control 1, 3
• History of recent falls or head injury 1