© 2011 National Safety Council 22-1
GERIATRIC PATIENTSLESSON 22
© 2011 National Safety Council 22-2
Introduction
• Older adults are an increasingly large proportion of American population
• Have more chronic health conditions that may lead to an emergency
• Much emergency care given to geriatric patients
• Be aware of possible age-related changes in geriatric patients and implications for assessment and treatment
© 2011 National Safety Council 22-3
Age-Associated Changes
• Changes gradually occur throughout lifespan
• By 65, human body has age-related changes in all body systems
• Changes generally continue throughout lifespan
• Rate and extent of changes depend on many factors
• Never make assumptions about any patient based on age
• Discrimination based on individual’s age is illegal
© 2011 National Safety Council 22-4
Changes in Sensory System
• All senses become less acute with aging
© 2011 National Safety Council 22-5
Changes in Vision
• Decreased general visual acuity
• Reduced ability to differentiate colors
• Diminished night vision
• Diminished near vision
• Decreased depth perception
• Visual impairments are more common
© 2011 National Safety Council 22-6
Changes in Hearing
• Decreased general hearing ability
• Increased use of hearing aids
• Diminished ability to hear high-pitched sounds
• Hearing impairments are more common
© 2011 National Safety Council 22-7
Changes in Touch and Pain
• Decreased sense of balance
• Diminished ability to differentiate temperature
• Decreased tolerance of hot and cold
• Diminished perception of pain
© 2011 National Safety Council 22-8
Changes in Smell and Taste
• Diminished smell and taste
• May cause reduced appetite and nutritional deficiencies
© 2011 National Safety Council 22-9
Changes in Cardiovascular System
• Heart muscle less powerful and blood vessels less elastic
• Rising blood pressure over the years may result in hypertension
• Diminished heart output
• Decreased functional blood volume
© 2011 National Safety Council 22-10
Changes in Cardiovascular System (continued)
• Reduced circulation and lower perfusion in some body areas such as legs
• Reduced ability of heart to beat faster when needed
• Increased risk of heart attack
• Increased risk of stroke
© 2011 National Safety Council 22-11
Changes in Respiratory System
• Less flexible alveoli in lungs, reduced gas exchange
• Less effective muscles for breathing
• Inhaled substances (such as tobacco smoke) cause other changes in lungs and airways
© 2011 National Safety Council 22-12
Changes in Respiratory System (continued)
• Diminished breathing capacity
• Decreased forcefulness of coughing (and reduced ability to cough out an airway obstruction)
• Increased risk of respiratory infections
© 2011 National Safety Council 22-13
Changes in Gastrointestinal System
• Stomach and intestines function less well
• Mouth changes, including use of dentures or other dental appliances, affect chewing and swallowing
• Difficulties chewing and swallowing increase risk of foreign body airway obstructions
• Digestive difficulties
© 2011 National Safety Council 22-14
Changes in Nervous System
• Slower reflexes increase risk of falls
• Diminished cough or swallowing reflexes
• Diminished short-term memory
• Other cognitive changes may affect behavior
• Dementia, Alzheimer’s and senility are not normal changes of aging but occur more commonly in older adults
© 2011 National Safety Council 22-15
Changes in Musculoskeletal System
• Decreased bone density: bones fracture more easily, even without trauma
• Osteoporosis decreases bone density
• Diminished size and strength of muscles
• Joint changes make arthritis more likely
• Curvature of upper spine is more common
© 2011 National Safety Council 22-16
Other Age-Related Changes
• Immune system and other changes may cause:
- Increased risk of many types of infections
- Less apparent signs and symptoms of infection when present (less likely to seek early treatment)
• More frequent loss of bladder or bowel control (preserve patient’s privacy and dignity)
• Less perspiring when warm (making heat emergencies more likely)
© 2011 National Safety Council 22-17
Chronic Disease
• Many chronic conditions are more common in geriatric patients
• Contributes to greater risk of injury or emergency illness
• Medications for chronic illness may have assessment and treatment implications
© 2011 National Safety Council 22-18
Age Implications for Assessment and Treatment
• Do not assume older individual is automatically different from other adults
• Be aware of age-related changes and implications for assessment and treatment
© 2011 National Safety Council 22-19
Primary Assessment
• Neck arthritis makes airway management more difficult
• Do not remove patient’s dentures for ventilation or rescue breathing unless they interfere
• Increased risk for airway obstructions caused by foreign body or swollen tissues from infection
• Pulse may be irregular due to arrhythmia
• If patient seems to have altered mental status or diminished cognition, ask family members about pre-emergency mental status
© 2011 National Safety Council 22-20
The Secondary Assessment
• Ensure lighting is adequate
• Position yourself at the patient’s eye level
• Speak slowly and distinctly
• Give patient time to respond
• Some geriatric patients may deny symptoms be thorough and use good communication skills
• Older adults are more susceptible to traumatic injury
• With reduced pain perception, injuries may not be immediately apparent
© 2011 National Safety Council 22-21
The Secondary Assessment(continued)
• Chronic medical conditions may increase likelihood of fall or other trauma
• Trauma more likely to cause bone fracture
• Normal vital signs depend on general physical and health status
• Vital signs may change rapidly with bleeding
• Seek detail about medications taken
• Medications may affect vital signs, blood clotting and other aspects of emergency care
• Patient may not show severe signs of illness even when very ill
© 2011 National Safety Council 22-22
• Depression is common and may affect patient’s behavior and communication
• Nutrition may be inadequate or home poorly heated or cooled
• Size up the scene for clues to patient’s condition
• With suspicious injuries, consider possibility of elder abuse
• Do not let many layers of clothing prevent you from adequate examination
• Reassess frequently because patient may deteriorate quickly
The Secondary Assessment(continued)
© 2011 National Safety Council 22-23
Implications for Treatment
• Handle patient very carefully
• With upper spine curvature, padding may be needed during spinal immobilization
• With decreased cough reflex, suctioning may be needed
• Prevent hypothermia in a cool environment
• Provide reassurance and support
© 2011 National Safety Council 22-24
Trauma
• Trauma often has more serious effects in geriatric patients
• Never assume any injury is minor based on mechanism of injury or because signs and symptoms do not seem severe
• Falls are a particular concern
- Cause fractures of hip, spine or other bones
- Treat all falls as severe or possibly life-threatening
© 2011 National Safety Council 22-25
Trauma (continued)
• Carry out physical examination carefully
• Manually stabilize or splint area
• Coinciding medical and traumatic emergencies more likely
• Never assume injury is only issue to be addressed
• Perform full secondary assessment with complete history
• Closely monitor vital signs and breathing
• Reassess more frequently
© 2011 National Safety Council 22-26
Medical Emergencies
• May be caused or exacerbated by chronic illness
• Common reason for EMR calls
• Signs and symptoms may not be classic picture
• Heart attack may not cause pain or chest symptoms
• Keep an open mind during assessment
© 2011 National Safety Council 22-27
Special Considerations in Medical Emergencies
• Denial of symptoms does not mean patient feels nothing
• Patient may not consider symptoms a concern
• Heart attack and stroke may produce minimal symptoms
• Never dismiss respiratory symptoms in geriatric patients
© 2011 National Safety Council 22-28
Special Considerations in Medical Emergencies (continued)
• Take thorough history of medications, consider accidental overdose or drug interaction
• Do not move patient from bed or wheelchair except for lifesaving care
• Remember dementia is not normal consider altered mental status related to illness
© 2011 National Safety Council 22-29
Elder Abuse
• Half a million elders in United States abused or neglected each year
• In 90% of cases, abusing person is family member
• The older a person is, the greater the risk for abuse
• Most likely abused are those who:
- Need help with daily activities
- Have lost bladder control
- Behave unusually because of altered mental status
© 2011 National Safety Council 22-30
Most Important Signs of Elder Maltreatment
• Frequent, unexplained crying
• Unexplained fear of or suspicion of particular person in the home
© 2011 National Safety Council 22-31
Signs and Symptoms of Physical Abuse
• Bruises, black eyes, welts, lacerations and rope marks
• Bone fractures, skull fractures
• Open wounds, cuts, punctures, untreated injuries, injuries in various stages of healing
• Strains, dislocations and internal injuries or bleeding
• Broken eyeglasses, physical signs of being subjected to punishment, signs of being restrained
© 2011 National Safety Council 22-32
Signs and Symptoms of Physical Abuse (continued)
• Medication overdose or underuse of prescribed drugs
• Elder’s report of being hit, slapped, kicked or mistreated
• Elder’s sudden change in behavior
• Caregiver’s refusal to allow visitors to see elder alone
© 2011 National Safety Council 22-33
Signs and Symptoms of Sexual Abuse
• Bruises around the breasts or genital area
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Torn, stained or bloody underclothing
• Elder’s report of being sexually assaulted or raped
© 2011 National Safety Council 22-34
Signs and Symptoms of Emotional/Psychological Abuse
• Emotional upset or agitation
• Extreme withdrawal, lack of communication and responsiveness
• Elder’s report of being verbally or emotionally mistreated
© 2011 National Safety Council 22-35
Signs and Symptoms of Neglect
• Dehydration, malnutrition, untreated bed-sores and poor personal hygiene
• Unattended or untreated health problems
• Hazardous or unsafe living conditions
• Unsanitary or unclean living conditions
• Elder’s report of being neglected
© 2011 National Safety Council 22-36
Signs and Symptomsof Abandonment
• Desertion of elder at hospital, nursing facility or similar institution
• Desertion of elder at shopping center or other public location
• Elder’s own report of being abandoned
© 2011 National Safety Council 22-37
Signs and Symptomsof Self-Neglect
• Dehydration, malnutrition, untreated medical conditions, poor personal hygiene
• Hazardous or unsafe living conditions
• Unsanitary or unclean living quarters
• Inappropriate or inadequate clothing, lack of necessary medical aids
• Grossly inadequate housing or homelessness
© 2011 National Safety Council 22-38
Emergency Care for Suspected Victims of Elder Abuse
• Perform standard assessment
• Perform standard patient care
• Give emergency care for injuries or illness found
• Ensure privacy while providing care
• Provide emotional support
• Do not directly confront patient with your suspicions, especially if family members are present
• Note everything patient says about cause of injuries
© 2011 National Safety Council 22-39
Emergency Care for Suspected Victims of Elder Abuse (continued)
• If you see physical abuse occurring or a crime committed, or if someone at the scene is threatening and potentially violent, call law enforcement personnel
• Tell responding EMS personnel in private about your suspicions
• Elder abuse is a mandatory reportable event
• Follow local protocol to document your observations and file appropriate report
• Be especially careful in your documentation
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