Transcript Chapter34

34: Geriatric Assessment and Management
Cognitive Objectives
(1 of 3)
1. Describe the following basics of patient
assessment for the geriatric patient:
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Scene size-up
Initial assessment
Focused history and physical exam
Detailed physical exam
Ongoing assessment
2. Discuss common chief complaints of older
patients.
Cognitive Objectives (2 of 3)
3. Describe trauma assessment in older patients for
the following injuries:
• Injuries to the spine
• Head injuries
• Injuries to the pelvis
• Hip fractures
Cognitive Objectives (3 of 3)
4. Describe acute illnesses in older people,
including:
• Cardiovascular emergencies
• Dyspnea
• Syncope and altered mental status
• Acute abdomen
• Septicemia and infectious disease
5. Discuss response to older patients in nursing and
skilled care facilities.
Psychomotor Objectives
6. Demonstrate the patient assessment skills that
should be used to care for an older patient.
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There are no affective objectives for this chapter.
All objectives in this chapter are noncurriculum
objectives.
Geriatric Assessment
• Geriatric assessment has unique challenges.
• The GEMS diamond can be a helpful tool.
• Preexisting conditions may affect findings.
Scene Size-up (1 of 2)
• Be keenly aware of the environment and
why you were called.
• Scene safety should include looking for
unsafe conditions.
• Look for hazards.
– Steep stairs, missing handrails, poor
lighting, other fall hazards
Scene Size-up (2 of 2)
• The general condition of the home will provide
clues.
– Cleanliness, heat, lighting, food
• Look for signs of activities of daily living.
– Personal hygiene, getting dressed, food
preparation
• Scene size-up continues throughout call.
Initial Assessment
• Never assume altered
mental status is normal.
• May have to rely on
family or caregiver to
establish patient’s
baseline LOC
• Assess the patient’s
chief complaint and
ABCs.
• History is usually the key
in helping to assess a
patient’s problem.
• Patience and good
communication skills are
essential.
• Treat the patient with
respect.
• Face the patient and
speak in a normal tone.
Focused History and
Physical Exam (1 of 2)
Focused History
and Physical
Exam (2 of 2)
• Medication history
– Often have multiple medication
– Obtain a list of medications and doses.
– Ask about medications recently started or
stopped.
– Determine if the patient has taken other
medications.
Medication Use
The average geriatric patient takes four or more
medications.
Detailed and Ongoing Exams
• Normal aging may affect physical findings.
– Increased BP, respiratory changes
• Chronic changes can mask acute problems.
• Ongoing assessments will help determine changes.
– Geriatric patients have decreased ability to
compensate.
Common Complaints
• Dyspnea
• Chest pain
• Altered mental
status
• Dizziness or
weakness
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Fever
Trauma
Falls
Generalized pain
Nausea, vomiting, and
diarrhea
Trauma Assessment (1 of 2)
• Common mechanisms of injury
– Falls
– Motor vehicle trauma
– Pedestrian accidents
– Burns
Trauma Assessment (2 of 2)
• Priorities in rapid trauma are the same.
• Confounding factors:
– Medical conditions or previous injuries
– Dentures or other dental implants
– Decreased ability to compensate
– Changes associated with aging
Injuries to the Spine
• Classified as stable or
unstable
• Osteoporosis is a
contributing factor to
spinal injuries.
• Prompt spinal
immobilization can
reduce further damage
and pain.
– Pad void spaces.
Head Injuries
• Assume a significant
injury in older patients
who have signs and
symptoms of head
injury.
• Suspect brain injury in
patients who take blood
thinners and who suffer
head injury.
• Maintain oxygen
delivery to brain.
Injuries to Pelvis and
Hip Fractures
• Often present as hip or buttock pain
• Pelvic ring disruption can lead to hemorrhage or
internal organ injury.
• Hip fractures:
– Common debilitating injury
– Maintain leg in static position to prevent further
injury.
Hip Fracture
Blanket rolls maintain the leg in a static position so
that further injury does not occur.
Medical Emergencies
• Determining chief complaint is challenging.
– Multiple conditions and complaints
– Ask what bothers them most today.
• Sensation of pain may be diminished.
• Fear of hospitalization
• Conditions may present differently.
Cardiovascular Emergencies
• Classic symptoms are often not present.
• Many have “silent” heart attacks.
• Common signs and symptoms
– Difficulty breathing
– Toothache
– Arm pain
– Back pain
Dyspnea
• Related to many causes
– Asthma
– COPD
– Congestive heart failure
– Pneumonia
• Provide oxygen for all patients experiencing
dyspnea.
Syncope
• Can occur for many
reasons in geriatric
patients
– Standing up too fast
– Straining to have bowel
movement
– Myocardial infarction
– Diabetic shock
Altered Mental Status
• Acute onset is not normal in any patient.
• Most sudden changes are caused by a reversible
condition.
• Evaluate and treat for hypoxia or hypoglycemia if
present.
Acute Abdomen
• Complaints of abdominal pain in older patients
usually indicate a serious event.
• Nervous system response to pain is lessened.
• Consider gastrointestinal problems or abdominal
aortic aneurysm.
Septicemia
• Results from presence of microorganisms or their
toxic products in bloodstream
• Patients may present with:
– Hot, flushed appearance
– Tachycardia and tachypnea
– Hypotension
– Chills, cough
Response to Nursing and
Skilled Care Facilities
• Important information to know from staff:
– What is the patient’s chief complaint today?
– What initial problem caused the patient to be
admitted to the facility?
• Ask the staff about the patient’s overall condition.
• Obtain any type of transfer papers.
Review
1. You arrive at the home of an 89-year-old woman with
an altered mental status. Her son and daughter are
both present, and tell you that she has diabetes,
hypertension, heart problems, and hypothyroidism.
Which of the following statements regarding this
scenario is NOT correct?
A. Determine the patient’s mental status the day before
B. An altered mental status is probably normal for her
age
C. An altered mental status indicates some brain
dysfunction
D. You should ask the family how the patient normally
behaves
Review
Answer: B
Rationale: Never assume that an altered mental
status is “normal” simply because of a person’s
age. Any alteration in mentation indicates some
degree of brain dysfunction and should be
evaluated by a physician. If family members are
present, try to determine if the patient’s current
mental status is typical for him or her, or if it has
changed. If it has changed, you must try to
determine when.
Review
1. You arrive at the home of an 89-year-old woman with an altered
mental status. Her son and daughter are both present, and tell you
that she has diabetes, hypertension, heart problems, and
hypothyroidism. Which of the following statements regarding this
scenario is NOT correct?
A. Determine the patient’s mental status the day before
Rationale: This is part of the assessment.
B. An altered mental status is probably normal for her age
Rationale: Correct answer
C. An altered mental status indicates some brain dysfunction
Rationale: This is part of the assessment.
D. You should ask the family how the patient normally behaves
Rationale: This is part of the assessment.
Review
2. When immobilizing the spine of a patient with
kyphosis, you should:
A. avoid the use of a long backboard.
B. use a vest-style device or short board.
C. use a scoop stretcher instead of a backboard.
D. place padding underneath the head as needed.
Review
Answer: D
Rationale: Kyphosis—a condition characterized by
flexion of the neck and an outward curvature of the
upper back—gives the patient a “hunchback”
appearance, and can make spinal immobilization
challenging. The outward curvature of the back
makes it more protuberant than the back of the
head; therefore, you should place padding
underneath the patient’s head to fill this void.
Review
2. When immobilizing the spine of a patient with kyphosis, you
should:
A. avoid the use of a long backboard.
Rationale: You should use some type of approved device long
enough to extend from the top of the head to the bottom of
the feet.
B. use a vest-style device or short board.
Rationale: This will not immobilize the lower spinal area.
C. use a scoop stretcher instead of a backboard.
Rationale: This is used to lift a patient to place the patient on a
long backboard.
D. place padding underneath the head as needed.
Rationale: Correct answer
Review
3. Because of the presence of arthritis, relatively
small hyperextension injuries of the neck can
cause the spinal cord to be squeezed, resulting in
weak or absent motor function that is more
pronounced in the upper extremities. This condition
is called:
A. a stable spinal injury.
B. an unstable spinal injury.
C. central cord syndrome.
D. a compression fracture.
Review
Answer: C
Rationale: In patients with arthritis, a relatively small
amount of neck hyperextension can squeeze the
spinal cord, resulting in a condition called central
cord syndrome. Central cord syndrome is
characterized by weak or absent motor function
that is more pronounced in the upper extremities.
Review
3. Because of the presence of arthritis, relatively small hyperextension
injuries of the neck can cause the spinal cord to be squeezed,
resulting in weak or absent motor function that is more
pronounced in the upper extremities. This condition is called:
A. a stable spinal injury.
Rationale: This injury has a low risk for leading to permanent
neurologic deficit.
B. an unstable spinal injury.
Rationale: This injury has a high risk of permanent neurologic deficit.
C. central cord syndrome.
Rationale: Correct answer
D. a compression fracture.
Rationale: This is a stable injury that often results from minimal
trauma.
Review
4. During your assessment of a 74-year-old woman
who experienced a syncopal episode, you take her
blood pressure while she is lying supine. After
sitting her up, you note a 15 mm Hg drop in her
systolic blood pressure. This MOST likely indicates:
A. a stroke.
B. dehydration.
C. a heart attack.
D. a normal finding.
Review
Answer: B
Rationale: Dehydration is common in geriatric
patients; it is often secondary to, among other
factors, a decreased thirst mechanism. Orthostasis
is a condition in which the systolic BP drops more
than 10 mm Hg when going from a lying position to
a sitting or standing position; it is highly suggestive
of dehydration.
Review
4. During your assessment of a 74-year-old woman who
experienced a syncopal episode, you take her blood pressure
while she is lying supine. After sitting her up, you note a 15 mm
Hg drop in her systolic blood pressure. This MOST likely
indicates:
A. a stroke.
Rationale: A stroke is an interruption of blood flow to the brain that
results in a loss of brain function.
B. dehydration.
Rationale: Correct answer
C. a heart attack.
Rationale: A heart attack occurs when a blood clot prevents blood
flow to an area of the heart.
D. a normal finding.
Rationale: This is not normal when associated with syncope.
Review
5. You respond to the home of a 90-year-old man who
complains of generalized weakness. When
assessing the patient, you should:
A. stand at or above his eye level.
B. turn on the lights and turn off the TV.
C. turn the patient’s hearing aids off if he wears them.
D. significantly elevate your speech when talking to
him.
Review
Answer: B
Rationale: When speaking to an older patient, as with any other
patient, you should stand at or below his or her eye level; this
position is less intimidating. Turning on the lights and turning off
the TV and/or radio will help the patient see and hear you better;
it will also remove any distractions, which will allow the patient to
focus on answering your questions. Hearing impairment is not
automatic with aging. If the patient is hearing impaired, speak
near his or her ear with normal or slightly elevated speech.
Hearing-impaired patients are usually unable to hear high-pitched
sounds; thus, significant elevation of your voice only distorts what
they hear.
Review
5. You respond to the home of a 90-year-old man who
complains of generalized weakness. When assessing the
patient, you should:
A. stand at or above his eye level.
Rationale: You should stand at or below the patient’s eye level.
B. turn on the lights and turn off the TV.
Rationale: Correct answer
C. turn the patient’s hearing aids off if he wears them.
Rationale: Have the patient put in his hearing aid, if he has one,
and turn it on.
D. significantly elevate your speech when talking to him.
Rationale: The elevation of your voice only distorts what the
patient hears.
Review
6. You are caring for a 76-year-old man with a
possible head injury. After assessing the patient
and applying spinal precautions, how should you
position the backboard on the stretcher?
A. Tilted to the left
B. Tilted to the right
C. Head slightly lower than the body
D. Head slightly higher than the body
Review
Answer: D
Rationale: Slightly elevating the head of the
backboard off the stretcher with a towel or blanket
can help reduce intracranial pressure following a
head injury. It may also make breathing easier by
preventing the diaphragm from elevating into the
thoracic cavity.
Review
6. You are caring for a 76-year-old man with a possible head
injury. After assessing the patient and applying spinal
precautions, how should you position the backboard on the
stretcher?
A. Tilted to the left
Rationale: There is no indication that the patient is vomiting or
has a potential airway problem.
B. Tilted to the right
Rationale: There is no indication that the patient is vomiting or
has a potential airway problem.
C. Head slightly lower than the body
Rationale: This will increase the pressure in the head.
D. Head slightly higher than the body
Rationale: Correct answer
Review
7. A 70-year-old woman was involved in a motor-vehicle
accident and was removed from her vehicle prior to
your arrival. After opening her airway, you note that she
is not breathing. When ventilating her, you are unable
to achieve adequate chest rise. Which of the following
would be the LEAST likely cause of this?
A. Congestive heart failure with pulmonary edema
B. Loose-fitting dentures that are obstructing the airway
C. Brittle ribs, which increases the risk of a pneumothorax
D. Larger lung capacity, which requires higher ventilatory
volume
Review
Answer: D
Rationale: Lung capacity decreases with age;
therefore, it typically requires lesser amounts of
volume to achieve adequate chest rise when
ventilating. In elderly patients, difficulty providing
rescue breathing could be caused by loose-fitting
dentures, which causes partial or complete
obstruction of the airway; pneumothorax due to
brittle ribs, which are more prone to fracture and
perforate a lung; and congestive heart failure with
pulmonary edema.
Review
7. A 70-year-old woman was involved in a motor-vehicle accident
and was removed from her vehicle prior to your arrival. After
opening her airway, you note that she is not breathing. When
ventilating her, you are unable to achieve adequate chest rise.
Which of the following would be the LEAST likely cause of this?
A. Congestive heart failure with pulmonary edema
Rationale: This could be a cause of the inadequate chest rise.
B. Loose-fitting dentures that are obstructing the airway
Rationale: This could be a cause of possible airway obstruction and
inadequate chest rise.
C. Brittle ribs, which increases the risk of a pneumothorax
Rationale: This could be a possibility of the inadequate chest rise.
D. Larger lung capacity, which requires higher ventilatory volume
Rationale: Correct answer
Review
8. When assessing and treating an elderly patient
who experienced a traumatic injury, it is important
to remember that:
A. the patient should be treated as a younger adult.
B. an underlying medical condition may have lead to
the injury.
C. padding behind the head should be avoided, even
in the presence of kyphosis.
D. older patients have a better chance for survival
because of the slow speeds they drive.
Review
Answer: B
Rationale: An underlying medical condition (ie,
hypoglycemia, heart attack, fainting, stroke) often
leads to a traumatic injury, such as a fall or motorvehicle crash, in elderly patients. When assessing
the patient, keep this in mind so you can properly
treat both the medical condition and traumatic
injury. Older patients have an increased mortality
rate following a motor-vehicle crash; their bones
are more brittle and prone to fracture and they are
less able to effectively compensate for blood loss.
Review
8. When assessing and treating an elderly patient who experienced
a traumatic injury, it is important to remember that:
A. the patient should be treated as a younger adult.
Rationale: The patient is older and you must be aware of the
changes that occur in the geriatric patient.
B. an underlying medical condition may have lead to the injury.
Rationale: Correct answer
C. padding behind the head should be avoided, even in the presence
of kyphosis.
Rationale: Padding may be necessary to immobilize the patient
appropriately.
D. older patients have a better chance for survival because of the
slow speeds they drive.
Rationale: This question does not indicate if the traumatic injury was
the result of driving.
Review
9. When preparing an 84-year-old woman with a
suspected hip fracture for transport, you should:
A. use a scoop stretcher if possible.
B. logroll the patient on the injured side.
C. pick the patient up using the shoulders and the
feet.
D. sit the patient up and slide a backboard under her
buttocks.
Review
Answer: A
Rationale: The scoop (orthopedic) stretcher allows
you to move a patient without the need to logroll
him or her. It is especially useful when moving a
patient with a suspected hip fracture. Never logroll
the patient onto the injured side; this would cause
unnecessary pain and could potentially worsen the
injury.
Review
9. When preparing an 84-year-old woman with a suspected hip
fracture for transport, you should:
A. use a scoop stretcher if possible.
Rationale: Correct answer
B. logroll the patient on the injured side.
Rationale: Never logroll a patient onto his or her injured side.
C. pick the patient up using the shoulders and the feet.
Rationale: You should try to keep the patient’s legs as straight
and still as possible to prevent additional injury.
D. sit the patient up and slide a backboard under her buttocks.
Rationale: The patient should remain in the supine position to
prevent additional pain and injury.
Review
10. When assessing an elderly patient with possible
cardiac compromise, it is important to recall that:
A. elderly patients are more likely to present with
asystole as the initial cardiac rhythm.
B. chest pain or pressure is present in greater than
95% of elderly patients with cardiac compromise.
C. elderly patients often present with atypical signs
and symptoms of cardiac compromise.
D. lethal cardiac dysrhythmias, such as ventricular
fibrillation, are more common in elderly patients.
Review
Answer: C
Rationale: Because of decreased pain sensitivity and
other factors associated with aging, elderly patient
often present with atypical signs and symptoms of
cardiac compromise. For example, the patient may
only present with nonspecific symptoms such as
nausea or weakness. Chest pain or pressure—
although present in approximately 80% of patients
with cardiac compromise—is less commonly
observed in elderly patients. Elderly patients are
neither less no more prone to lethal cardiac
dysrhythmias as younger adults.
Review (1 of 2)
10. When assessing an elderly patient with possible cardiac
compromise, it is important to recall that:
A. elderly patients are more likely to present with asystole as
the initial cardiac rhythm.
Rationale: There are no significant differences in the types of
lethal dysrhythmias.
B. chest pain or pressure is present in greater than 95% of
elderly patients with cardiac compromise.
Rationale: Elderly patients often present with atypical signs and
symptoms — this includes a lack of chest pain or pressure.
Review (2 of 2)
10. When assessing an elderly patient with possible cardiac
compromise, it is important to recall that:
C. elderly patients often present with atypical signs and
symptoms of cardiac compromise.
Rationale: Correct answer
D. lethal cardiac dysrhythmias, such as ventricular fibrillation,
are more common in elderly patients.
Rationale: There are no significant differences in the types of
lethal dysrhythmias.