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Transitioning to Adult-Gerontology APRN Education: Slide Library Assessment and Management of Atypical Presentation of Illness in Older Adults Author: Deanna Gray-Miceli, PhD, RN, GNP-BC, FAANP Adult-Gerontology APRN Slide Library • The APRN Slide Library is a resource of “Transitioning to Adult-Gerontology APRN Education” a project of AACN and the Hartford Institute for Geriatric Nursing 2010-2012 • The project is funded by the John A. Hartford Foundation Adult-Gerontology APRN Slide Library "All materials are jointly copyrighted by the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University or are used with permission from the original source. Permission is hereby granted to reproduce, post, download, and/or distribute, this material for not-for-profit educational purposes only, provided that the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University are cited as the source. They may not be used for ANY commercial or other purpose." Available at www.hartfordign.org E-mail notification of usage to: [email protected] Further information about the APRN program can be found at www.aacn.nche.edu/APRN Gerontology.htm Purpose of the APRN Slide Library – Atypical Presentation of Illness • To provide APRN faculty with an overview of atypical presentation of illness in older adults* • To introduce APRN faculty to print and web resources on assessment, diagnosis & management of atypical presentation of illness • To provide APRN faculty with slides on atypical presentation to use in class & to share with APRN students * These slides have been modified from slides prepared for the Geriatric Nursing Education Consortium (GNEC) program (www.aacn.nche.edu) Adult-Gerontology APRN Slide Library Web Resources http: //www.ConsultGeriRN.org Try This ® and How to Try This General Assessment Series, e.g. • Assessment of Pain in Older Adults http: //www.ConsultGeriRN.org Try This ® and How to Try This Dementia Assessment Series, e.g. • Recognition of Dementia in Hospitalized Older Adults http: //www.ConsultGeriRN.org select Evidence-based Geriatric Topics, e.g. protocol on Atypical Presentation of Illness Source Books: Geriatrics Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011) • • • A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition Authored by > 100 interdisciplinary experts in care of older adults 59 chapters on prevailing management strategies, extensive reference, appendix with assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/ Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into Advanced Practice Nursing Education. New York: Springer Publishing Co. • • • • Clear, user-friendly guidelines for integrating gerontological content into non-gerontological APRN programs Detailed lists of print resources and e-Learning materials Utilizes a competency-based framework “Success stories” written by APRN faculty who have integrated gerontological content into non-gerontological courses Atypical Presentation of Illness - Introduction APRNs in all practice settings need to recognize acute, chronic and/or complex illness in older adults may present atypically Integral to the history and physical is the ability to determine if an older adult is presenting atypically Early diagnosis of atypical presentation of illness reduces morbidity and mortality, and reduces the rate of co-morbidity from treatable geriatric syndromes Atypical Presentation: Definition Atypical presentation is defined as non-specific symptoms occurring outside of the normal rubric of traditional signs and symptoms, which may signify an impending acute illness in an older adult. Non-specific signs and symptoms may include: Confusion Unexplained change in behavior or function Falls Incontinence Apathy Poor appetite; anorexia Dyspnea Fatigue or excessive sleepiness Atypical Presentation Atypical presentation of illness can include: vague presentation of illness altered presentation of illness non-presentation of illness Classic Signs and Symptoms of Atypical Presentation of Illness in Older Adults Signs and Symptoms Acute confusion (for example “delirium”) Failure to eat or drink (for example, anorexia) Failure to develop a temperature or fever in light of leukocytosis Lack of pain with a disease known to cause pain (such as gastric ulcer disease) Signs and Symptoms Functional decline Reduced mobility Generalized weakness Falling Fatigue Urinary Incontinence Atypical Presentation and Delirium Case Study Delirium is a common manifestation of an atypical presentation of illness For information and resources on delirium, See Slide Library: Delirium over 60 percent of frail hospitalized older adults with atypical presentation experienced delirium Classic and Variant Symptoms of an Acute Myocardial Infarction (MI) Classic signs observed with an MI Substernal chest pain Radiating pain to neck, jaw or arm Shortness of breathe/dyspnea Atypical presentation of MI Mild or absent pain Acute confusion Mild or absent dyspnea Diaphoresis Electrocardiogram evidence of infarction No electrocardiogram evidence or Non-Q wave infarction or silent (no symptoms) Myocardial infarction Clinical Manifestations of Infection in Residents of Long-term Care Facilities (Infections of the urinary tract, respiratory, skin and soft tissue, gastrointestinal and/or bacteremia) Typical findings of infection Atypical findings of infection Fever Change in mental status Cough and yellow sputum (respiratory infection) Change in cognition function Heat, redness, purulence and skin breakdown (pressure sore infected) Decline in physical function ( for example: inability to perform activities of daily living or new onset of incontinence, falling or failure to cooperate in rehabilitation) New onset of skin lesions (scabies infestation in the institutionalized setting) Clinical Manifestations of Infection in Residents of Long-term Care Facilities (continued) Typical findings of infection Atypical findings of infection Afebrile (15 percent of bacteremic patients who are elderly are afebrile) Tachypnea (respiratory rate greater than 25 breaths/minute) Dehydration (clinical observation coupled with elevated laboratory assays, e.g. BUN) Case Reports of Atypical Presentation of Illness in Older Adults Case reports of atypical presentation of illnesss among older adults, particularly those of advanced age are very common, spanning from diseases afflicting the central nervous system to the gastrointestinal and cardiovascular systems Pain is often an acute heralding feature associated with the onset of many diseases in younger adults, but the same can’t be said of pain presentation with diseases in older adults Case Report Gastrointestinal ulcer or reflux disease, myocardial infarction or a urinary tract infection generally present with pain among younger adults. These same diseases do not however, necessarily present with pain in older adults Case Reports of Atypical Presentation of Illness in Older Adults Case Reports Older adults with acid-related diseases of the gastrointestinal tract due to medications, peptic ulcer disease or gastro-intestinal reflux disease [GERD], pain reported was subtle, atypical or absent Older adult women with coronary heart disease, atypical symptoms were present during the infarction; and for these women a delay in diagnosis occurred Myocardial infarction in older adults, particularly those of advanced old age can include vague and non-specific symptoms such as minimal or no chest pain, no shortness of breath or acute confusion Case Reports of Atypical Presentation of Illness in Older Adults Change of behavior or function is an early marker of an underlying health problem or serious condition in an older adult Case Reports 73 year-old man with dementia and behavioral difficulty including anxiety and agitation were wrongly attributed to dementia When treated with medications for this “behavioral” problem, the agitation was found to be associated with physiological blood pressure change and surges of catecholamine, later diagnosed as a pheochromocytoma Note: Behavioral agitation and anxiety of a new onset and duration was a symptom indicating a potential problem. The physical sign of escalation of blood pressure correlated with this symptom of behavioral agitation to further confirm that something other dementia was occurring. Atypical Presentation of Illness: Patients at Greatest Risk Older adults: Over age 85 With multiple comorbidities; the "frail" elderly On multiple medications With cognitive or functional impairment IMPORTANT Atypical Presentation: Diagnosis Diagnosis of atypical presentation is contingent on: 1. Knowledge as to it's prevalence among older adults 2. A problem- focused history 3. A focused physical examination 4. Critical analysis and heightened awareness of the possibility for any given older patient Problem-Focused Hx & PE The APRN Hx and PE should actively assess for “tell tale signs” that may be part of an atypical presentation These include changes in behavior such as restlessness or agitation, anxiety or changes in cognition Note that physical findings such as fever or leukocytosis are often absent or modified in atypical presentation Atypical Presentation: Diagnosis APRN Actions • Assess for pain and delirium using standardized, validated scales. • Order frequent vital signs and core or rectal temperature to determine the presence of hypothermia related to bacteremia • Initiate strict I & O, assess oral mucosa for dehydration; check serum electrolytes, BUN/ creatinine & CBC •Calculate the glomerular filtration rate;a djust medications & fluids according ly • Order chest Xray & urinalysis Atypical Presentation: A Systems Approach Facility level protocols to identify atypical presentation can assist in the step-by-step approach to interventions Protocols should reflect immediate, interim, and followup actions, whereby interventions are prioritized according to the medical stability of the patient Clinical practice guidelines can be useful in managing older adults thought to be presenting atypically, provided that they specifically address this issue Conclusion When APRNs caring for older adults routinely detect and act upon important signs and symptoms associated with atypical presentation of illness, important health outcomes can be realized.