Joan Somes

Extended ED Stay of the Older Adult Results in Poor Patient Outcome

No matter what the size or location of your emergency department it is time to critically evaluate the patient care issue and impact of a delayed admission. Our case study centered on a trauma patient and the need for trauma protocols and trained staff. The good news about our case study is that it took place some time ago and since then the hospital has developed trauma protocols as they diligently work toward level 4 trauma certification. Similar protocols should be developed for critically ill patients. While our number 1 goal is to improve patient care and patient satisfaction, the financial bottom line of your facility will be impacted by the negative effects of this issue.

Geriatric Emergency Nursing: Case Study

JEN will regularly feature this new column by Nancy Stephens Donatelli, RN, MS, CEN, NEA-BC, and Joanie Somes, RNC, PhD, CEN, CPEN, FAEN. An ENA member survey identified the top list of geriatric nursing education needs as: differences in pathophysiology associated with differences in the geriatric patient, pharmacology and medication administration, falls, geriatric safety, and sensory changes. This series addresses reader interest in and questions regarding the care of the older adult. The editors request feedback and ideas from JEN readers regarding learning needs related to caring for the geriatric patient in the emergency department. Please E-mail your specific questions or suggestions to question4gene@gmail.com. The editors will collect reader responses and answer as many as possible via E-mail or in JEN .

Serotonin syndrome-muscle rigidity and confusion in the older adult.

Margaret, an 82-year-old woman, is brought to the emergency department confused and “not acting right.” On arrival, she is confused, restless, diaphoretic, and lacks coordination as she reaches for items (such as the pen). Her blood pressure is 220/110 mm Hg, heart rate irregular at 120 bpm, respiratory rate 24 per minute, and temperature 102.5°F. The paramedics share that the assisted living home staff were very concerned because Margaret is normally “sharp as a tack!” As Margaret is assessed, she is found to be confused regarding date, time, and location, and she is unable to provide a good history. A medic alert tag indicates she is a diabetic and has an allergy to penicillin.Her lack of coordination is equal, as opposed to one sided. She has no facial droop or unequal grasp. (This seems to decrease likelihood of a stroke.) Pupils are equal and reactive. Her lungs are clear. A 12-lead EKG shows atrial fibrillation with a rapid response and no acute changes. Finger stick glucose is 120 mg/dL. Her abdomen is mildly tender, with hyperactive bowel sounds, and Margaret has been slightly incontinent of stool. Her lower left leg is scaly, red, hot, and swollen. There is serous discharge from an open area on the leg, and it appears that Margaret has been scratching the area. During assessment, Margaret is noted to have become even more tremulous and hyperreflexic than she was on arrival. Fortunately, there is a pill bottle in the purse brought with Margaret. The bottle is labeled linezolid; “take twice a day.” It has Margaret’s name and the previous day’s date on it. The medication was dispensed from a 24-hour chain pharmacy.

SYNDROMES OF "HOLIDAY HEART"

I t is the week of the holidays and an interesting group of older adult patients present to the emergency department. Each has symptoms caused by common holiday activities that lead to medical problems. Sophia presents to the emergency department with “swelling in her ankles.” Thomas has palpitations and shortness of breath. Annette has pressure in her chest. George’s daughter feels George has a urinary tract infection, and Carolina developed weakness during church services. What is the underlying cause(s) of their symptoms? Sophia, age 86, is alert, oriented, and generally in good health. Her only medications are a multivitamin and aspirin. The swelling in her ankles has been going on for the last couple days. This is now a problem for Sophia because she is unable to get into her party shoes and her “holiday rings are getting a little tight.” Sophia shares that she likes to dress up, has attended several parties this past week, and has several more to go! “This swelling stuff has to stop!” She denies chest pressure, shortness of breath, nausea, or sweating. Her blood pressure is 146/80 mm Hg, heart rate 78 beats per minute, regular; respirations 20 with oxygen saturations of 98%, and temperature 98.6°F. Lung sounds are clear and she is in a normal sinus rhythm. She definitely has puffy ankles, feet, and hands. When asked if she ever had this before, she chuckles, saying, “many years ago, when I was chubby I did sometimes have to take a water pill for fluid.” Since losing weight and watching her diet, it has not been a problem. What is going on with Sophia? Thomas is 64 years of age. “I woke up with palpitations, my chest is tight, and I’m short of breath.” You note his pulse is fast and slightly irregular; cardiac monitor shows a narrow, complex, irregular tachycardia at 186 beats per minute. His blood pressure is 142/80 mm Hg, and respirations are 24 with bilateral mild crackles at the bases of his lungs. Oxygen saturation is 93% on room air, and he has good pulses throughout. Thomas does not normally take any medications, denies smoking, and he does not drink alcohol; however, his breath smells of alcohol, and upon further questioning admits he was at his company’s holiday party last night and he had “several drinks.” His 12-lead EKG shows rapid, narrow, irregular complexes, but no ST elevation. Oxygen has not changed the shortness of breath; oxygen saturation is now 95%. He rates the chest tightness at 2 on a 0 to 10 scale. What is up with Thomas? Annette is 75 years of age and complains of pain in her chest. The pain has been going on for the last couple weeks and is worse at night and in the evening. She lives alone since the death of her husband of 55 years earlier in the fall. “I can’t get into the holiday spirit. It’s not worth it to put up a tree or decorations, or bake since I don’t have anyone to share the holidays with.” All this information tearfully spills out of Annette in response to the question, “how long have you had the pain?” She also shares that she is tired, nauseated to the point she does not feel like eating, and often short of breath. Her monitor shows atrial fibrillation at 78 beats per minute; blood pressure of 138/76 mm Hg; respirations 20 and lungs clear; oxygen saturation of 99%; temperature 98.6°F; and 12-lead EKG shows no acute changes. Annette takes aspirin, an antidepressant, and a high blood pressure pill. What is happening with Annette? George is 68 years of age and his daughter seems to do much of the talking. She wants him “checked for a urinary tract infection. He has to go frequently, is hot, and has back pain.” George, when he gets to talk, says he is afraid of putting his daughter out by not feeling well, as he knows she has many holiday events planned that include him. So far he has visited half of his children during this trip. He shares: “I usually enjoy the holidays, especially the holiday foods, but it is harder this year since I was recently diagnosed with diabetes.” He admits he forgot his blood sugar measuring device at home, so even though he is on a sliding scale for his insulin dose, he has been “ball parking” the insulin amount by injecting the typical amount of insulin he used at home. Other medications include a beta blocker, Joan Somes, Member, Greater Twin Cities Chapter ENA, is Staff Nurse/ Department Educator, St. Joseph’s Hospital, St. Paul, MN.

Beers List: What’s NOT on “Tap” for the Older Adult

n 82-year-old female patient presents to your emergency department with her daughter. The Apatient complains of “feeling dizzy and weak.” The treat symptoms arising from an unrecognized adverse drug daughter tells you that for the past 2 days, her mother, who is normally bright, active, and engaged in many household activities, has suddenly had periods of confusion and difficulty “getting herself together.” She indicates that this behavior seems to become worse over the course of the day and her mother has not been sleeping well at night. Her mother fell last night when going to the bathroom. The patient said she gets “dizzy” when she stands up. You note that the patient is pale and seems anxious. Her vital signs are well within normal limits, and she has no complaints of pain. Her medical history includes type 2 diabetes mellitus, hypertension, and arthritis, and most recently, she has been diagnosed with gastroesophageal reflux (GERD). A review of medications includes the following: chlorpropamide (Diabinese), 250 mg daily; metoprolol (Lopressor), 100 mg twice daily; acetaminophen (Tylenol), 500 mg twice daily; and fish oil, 500 mg daily. Two weeks ago, the patient’s family doctor added metoclopramide (Reglan), 10 mg 4 times daily, for complaints of nausea and heartburn thought to be caused by GERD. The emergency physician ordered a complete blood count, blood sugar, urinalysis, and chest radiograph looking for a site of infection that was precipitating the delirium-like symptoms. All of the testing returned with normal findings.

Sedation and Pain Medications in the Older Adult

Mary, age 85 years, presented to triage with a painful right forearm that she injured in a fall the previous day. Her right hand and forearm were double the size of the left and were ecchymotic but warm with good capillary refill. The wrist, even with the swelling, had an obvious bony deformity. Distal color, motion, and sensation were intact, as were the pulses in the arm. She looked amazingly comfortable and moved the arm freely from the shoulder. When asked for a pain rating, she gave it a 4 to 5 on a 10-point scale. She did admit, “I took an ibuprofen yesterday.” She stated that she had tripped on a rug, she had not lost consciousness, and she had no other injuries. Further questioning revealed that Mary generally was in good health. She lived independently and initially listed aspirin, taken daily, as her only medication. When questioned further, she added that she also took fish oil and a multivitamin. Mary’s wrist and forearm were placed on a pillow that also served to splint and elevate the extremity. Ice packs were applied. The primary nurse re-assessed the arm and found that not only did Mary have a nasty-looking wrist, but her elbow was painful to movement and touch. Mary had no complaints of shoulder pain. Radiographs of the elbow and wrist were ordered, which showed that the patient had fractured and dislocated the distal radius and ulna. In addition, she also had dislocated her elbow. The staff were amazed that her color, motion, sensation, and pulses were so good despite the dislocation, swelling, and length of time since the injury. The staff also were surprised at the low pain score she gave this injury. An orthopedic consultation was arranged. Knowing that the patient had eaten prior to coming to the emergency department, the primary nurse expected that Mary’s arm would be splinted and that she would be admitted and go to surgery for definitive care later in the day. The nurse was somewhat surprised when the ED physician ordered medications so he could emergently reduce the elbow. The order read: “Start by giving 100 mcg of fentanyl and 2 mg of midazolam IV.” The physician then told the nurse, “We will titrate up based on response.” Mary had been given 2 oxycodone with Tylenol about 45 minutes earlier and was already drowsy. The midazolam and fentanyl, when administered together, are considered procedural sedation. The nurse arranged to have help available during and after the procedure, and she advised the charge registered nurse that she would be unavailable during, as well as longer than usual, after the procedure. Aging often leads to different responses to medications, but especially to sedating and pain medication, when compared with the same amount administered to a younger patient. The brain of the older adult is more sensitive to benzodiazapines, opioids, and anesthetic agents such as propofol. Many geriatric patients are “medication naïve,” meaning smaller doses may have a more profound effect on the individual because of a lack of tolerance to narcotics, opioids, and analgesics. A more frequent incidence of delirium has been seen in older patients who have received higher doses of sedating medications, although this situation generally is not an immediate concern in the emergency department. Increases in body fat, decreases in lean body mass, total body water content, and relative changes in protein constituents affect drug pharmacokinetics. Decreased levels of body water tend to lead to higher peak concentrations than expected after bolus doses are administered. Joan Somes, Greater Twin Cities Chapter ENA, is Staff Nurse/Department Educator, St Joseph’s Hospital, St Paul, MN.