9/7/15 1 Care of the Injured Patient: A Geriatric Perspective Kara Jones MSN, RN, FNPBC Jenna Kesey MSN, RN, FNPBC, CWS Disclosures • None to add, Objectives 1) Identify differences in physiology for the aged patient. 2) Identify the significance of geriatric injuries to morbidity and mortality. 3) Pinpoint system based modifications in management of the traumatically injured geriatric patient. 4) Understand management principles for caring for the thermally injured geriatric patient. 5) Utilize appropriate resources to maximize outcomes for the geriatric injured patient. University Medical Center: Service is Our Passion Why I Care about Geriatric Trauma Geriatric Trauma: A PublicHealth Issue • Geriatric population: aged >60 years. • Over 10% of total population. • Most rapidly growing segment of the US population. (Administration on Aging, 2015) (Census Bureau, 2010)
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
9/7/15
1
Care of the Injured Patient: A Geriatric Perspective
Kara Jones MSN, RN, FNP-‐BCJenna Kesey MSN, RN, FNP-‐BC, CWS
Disclosures
• None to add,
Objectives1) Identify differences in physiology for the aged
patient.2) Identify the significance of geriatric injuries to
morbidity and mortality.3) Pinpoint system based modifications in
management of the traumatically injured geriatric patient.
4) Understand management principles for caring for the thermally injured geriatric patient.
5) Utilize appropriate resources to maximize outcomes for the geriatric injured patient.
University Medical Center: Service is Our Passion
Why I Care about Geriatric Trauma
Geriatric Trauma:A Public Health Issue
• Geriatric population: aged >60 years.• Over 10% of total population.• Most rapidly growing segment of the US population.
(Administration on Aging, 2015)(Census Bureau, 2010)
9/7/15
2
The Issue Continues• 33% of trauma health care expenditures.• $30 billion per year in direct & indirect costs.• 4th leading cause of death in all age groups• 8th leading cause of death in those 65 years and older.
• 40% of trauma admissions related to falls.• 10%-‐15% of all emergency department visits.• Leading cause of non fatal injuries.• >60% discharged somewhere other than home.
• Top 20 non fatal causes of injury• <1940, no geriatric patient survived >10% TBSA• Survival dependent on many factors• Mortality= 50% in a 25% TBSA for >70 years old
100% in a 40% TBSA for >80 years • COPD independently associated with mortality
modifications in management of the traumatically injured geriatric patient.• EAST guidelines: – avoid under triage – rapidly correct coagulopathy – admit to ICU if base deficit <-‐6mEq/L – SBP<90 associated with 82% mortality rate– GCS <8 x 72 hours warrants supportive care discussion.
• American College of Surgeons-‐Committee on Trauma (ACS-‐COT)– Inclusive trauma system– Pre-‐hospital trauma care–Multidisciplinary approach– Rehabilitation
American College of Surgeons, 2014
Trauma Guidelines
• American College of Surgeons: Trauma Quality Improvement Program (ACS-‐TQIP)– Trauma team activation– Initial evaluation– Specialized geriatric inpatient care– Decision making and care preferences– Discharge
American College of Surgeons, 2014
More Guidelines
• Other guidelines:– American Association for Surgery of Trauma (AAST)– American Geriatrics Society (AGS)– American Burn Association (ABA)– American Family Physician (AFP)– American College of Emergency Physicians (ACEP)– American Association of Nurse Practitioners (AANP)– And on, and on, and on . . .
• Delirium/Dementiaorient to day/nightOOB activitesoutsidelimit offending drugslimit night time interruptions• Alcohol/Drug Withdrawal
give beersvitamin supplementationCIWA protocol
BEERS criteria
Nonbenzodiazepine hypnotics •
Eszopiclone• Zolpidem• Zaleplon
These medications may
not s ignificantly improve s leep and can cause many ser ious s ide effects , including confus ion, falls , and bone
fractures .
Avoid ongoing use of these drugs
(over 90 days ).
Dabigatran
This medication, used to prevent
the formation of blood clots in patients with atr ial fibr illation, increases the chance of bleeding in
adults 75 years and older more than another drug, war far in, that is
used for the same purpose. There isn’t enough evidence that dabigatran is effective and safe in
patients with kidney problems .
Use this drug with caution in adults
75 and in older adults with kidney problems .
American Geriatrics Society, 2012
BEERS Criteria
Ben zod iazep in es
Short- and i ntermedi ate-acti ng: • Alp razo lam • E stazo lam • Lorazep am • Ox azep am • Temazep am • Tri azo lamLong-acti ng: • Ch lorazep ate
• Ch lord iazep ox id e • Ch lord iazep ox id e-ami trip tyl in e• Cl id in iu m-ch lord iazep ox id e • Clon azep am• Diazep am
• Flu razep am• Qu azep am
Old er ad u l ts are esp eci al l y sen si ti ve to th ese
med ication s. Th ese d ru gs may in crease ri sks o f men tal d ecl in e, d el i riu m, fal l s, fractu res, an d car accid en ts in o ld er ad u l ts. Desp i te th ese ri sks, th ey may b e ap p rop ri ate, i n certain cases, for treatin g sei zu res, certain
sleep d i sord ers, an x iety d i sord ers, wi th d rawal from b en zod iazep in e d ru gs an d al coh o l , an d en d -o f-l i fe care.
Avo id b en zod iazep in es
(al l typ es) wh en treatin g in somn ia, agi tation , or d el i riu m (seriou s con fu sion th at may h ave l astin g effects).
Insomnia
Oral deconges tants •
Pseudoephedr ine • Phenylephr ine Stimulants
• Amphetamine• Methylphenidate • Pemoline
Other medications • Theophylline
• Caffeine
These drugs make
insomnia worse. Avoid
BEERS Criteria
Del i riu m
Al l Tri cycl i c Antid epressan ts (TCAs)Al l An ti cho linergi c drugs Benzodiazepines Ch lorp romazin e Corticosteroids H2-receptor an tagon i st Mep erid in e Sed ati ve h yp n oti cs Th iorid azin e
Th ese med ications can cau se or worsen d el i riu m in older people. Avoid these drugs in o ld er ad u lts with or at hi gh risk o f del i riu m.
Avo id
Demen ti a an d cogni ti ve/ mental impai rment An ti ch o l in ergic d rugs Ben zodiazep ines H2-recep tor an tagon ists Zolpid em An tip sych oti cs—used regu larl y or as needed
Avo id th ese dru gs in adu lts with cogni ti ve or “th in kin g” problems b ecause these med ication s may make thi s worse. An tip sych oti c drugs should not be prescribed for b eh avioral problems rel ated to d ementi a u n less n on-drug or safer dru g options are not workin g an d a p atien t i s a th reat to himsel f or oth ers. Antipsychotic d ru gs may in crease th e chance o f stroke and d eath in people with demen tia.
Medication sentences are per dose. You will need to calculate a total daily dose if needed.
**Both lorazepam options should be ordered to align with the CIWA-Ar treatment protocol. If the decision is made not to order one or both of the lorazepam orders, provide clear instructions for treatment of alcohol withdrawal.**
LORazepam
1 mg, IVPush, inj, q2h, PRN agitation Give for CIWA-Ar score of 9-15. Maximum dose of 24 mg/24 hr. Reassess patient in 2 hours and treat based on CIWA-Ar Score.
LORazepam
2 mg, IVPush, inj, q1h, PRN agitation Give for CIWA-Ar score greater than 15. Maximum dose of 24 mg/24 hr. Reassess patient in 2 hours and treat based on CIWA-Ar Score.
IV Vitamins
Banana Bag (NS) Continuous
IV, mL/hr Give once every 24 hours. Hold main IVFluids while banana bag is infusing. 1 mg, Every Bag 100 mg, Every Bag
***Consider high dose thiamine in patients with diagnosis of Wernicke’s Encephalopathy***
thiamine
500 mg, IVPB, ivpb, TID, x 3 days
Oral Vitamins
folic acid
1 mg, PO, tab, Daily
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 1 Alcohol Withdrawal Syndrome Plan Version: 4 Effective on: 01/05/15 1201
Page 1 of 2
UMC Health System Patient Label Here
ALCOHOL WITHDRAWAL SYNDROME PLAN
PHYSICIAN ORDERS
Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.
ORDER ORDER DETAILS
multivitamin 1 tab, PO, tab, Daily
thiamine 100 mg, PO, tab, Daily
TO Read Back Scanned Powerchart Scanned PharmScan
Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________
Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________
Page: 2 Alcohol Withdrawal Syndrome Plan Version: 4 Effective on: 01/05/15 1201
Page 2 of 2
CIWA-‐ArClinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______
NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation.0 no nausea and no vomiting1 mild nausea with no vomiting234 intermittent nausea with dry heaves567 constant nausea, frequent dry heaves and vomiting
TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation.0 none1 very mild itching, pins and needles, burning or numbness2 mild itching, pins and needles, burning or numbness3 moderate itching, pins and needles, burning or numbness4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations
TREMOR -- Arms extended and fingers spread apart. Observation.0 no tremor1 not visible, but can be felt fingertip to fingertip234 moderate, with patient's arms extended567 severe, even with arms not extended
AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation.0 not present1 very mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations
PAROXYSMAL SWEATS -- Observation.0 no sweat visible1 barely perceptible sweating, palms moist234 beads of sweat obvious on forehead567 drenching sweats
VISUAL DISTURBANCES -- Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation.0 not present1 very mild sensitivity2 mild sensitivity3 moderate sensitivity4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations
ANXIETY -- Ask "Do you feel nervous?" Observation.0 no anxiety, at ease1 mild anxious234 moderately anxious, or guarded, so anxiety is inferred567 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.0 not present1 very mild2 mild3 moderate4 moderately severe5 severe6 very severe7 extremely severe
AGITATION -- Observation.0 normal activity1 somewhat more than normal activity234 moderately fidgety and restless567 paces back and forth during most of the interview, or constantly thrashes about
ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?"0 oriented and can do serial additions1 cannot do serial additions or is uncertain about date2 disoriented for date by no more than 2 calendar days3 disoriented for date by more than 2 calendar days4 disoriented for place/or person
Total CIWA-Ar Score ______Rater's Initials ______
Maximum Possible Score 67
The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.
Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989.
What is SBIRT
• Screening, Brief Intervention, and Referral to Treatment.
• DMStart home medicationsCheck HbgA1cDiet educationIM/PCP consult
• HypothyroidStart home medicationsCheck thyroid panel
• Electrolyteskeep in the “box”sneaking medication
Hematology &Infectious Disease
• AnemiaTransfuse if necessaryCheck under operative dressings
• CoagulopathyCorrectIs anticoagulation needed?
• LeukopeniaMyelodysplastic syndrome?
• HAP vs CAPTreat with antibiotics appropriatelyRespiratory consultDaily chest x ray
• UTITreat appropriatelyRemove foley catheter
• Wound infectionsTake down operative dressingsCheck buttocks for decubitus
Musculoskeletal
• FracturesEarly mobilityOOBDischarge planningAssistive devices in roomPain control
• OsteoporosisDiagnosticsTreatRefer to osteoporosis
clinic
Progressive Mobility Protocol
� TO � Read back Order taken by Signature: ________________________________________Date/Time: _____________________________ Physician Signature__________________________________________ Date/Time_____________________________
Page 1 of 2- ICU Progressive Mobility Plan 05/07/2012 (#1076 R-1)
Perform each step of progressive mobility for at least 30 to 60 minutes three times a day. Repeat each step until patient demonstrates hemodynamic and physical tolerance then advance to next step at the next activity period.
Step 1: HOB elevated to 45 degrees
Step 2; HOB elevated to 45 degrees and legs in dependent position (partial chair mode)
Step 3: HOB elevated to 65 degrees and legs in full dependent position (full chair mode)
Reconsult Physical Therapy for evaluation and treatment when ready to progress to Step 4
Step 4: HOB elevated to 65 degrees plus legs in full dependent position and feet on the floor plus standing.
Step 5: Initiate stand/pivot and into chair
Step 6: Initiate stand/pivot with march stepping and into chair
ICU PROGRESSIVE MOBILITY PLAN
Patient Label Here
� TO � Read back Order taken by Signature: ________________________________________Date/Time: _____________________________ Physician Signature__________________________________________ Date/Time_____________________________
Page 2 of 2- ICU Progressive Mobility Plan 05/07/2012 (#1076 R-1)
Progressive Mobility Algorithm
ICU PROGRESSIVE MOBILITY PLAN
Patient Label Here
Is patient at risk for deconditioning due to immobility?
Assess patient for the following: Lobar collapse, atelectasis, excessive secretions, P/F ratio < 300, Hemodynamic instability with manual turning
CLRT
Initiate Progressive Mobility
Assess skin q 4 hours. Temporarily offload pressure areas as necessary for circulatory recovery. Wedges are not to be used during rotation.
Y
N
N Ambulate
Y
Reassess every shift
9/7/15
8
Wounds/Lines/DrainsProphylaxis• Wounds• Central lines• Drains• NGT/DHT/PEG/JP
Remove early as appropriateObtain peripheral if neededPromotes mobilization
• Mechanical prophylaxisSCDS/foot pumps
• Chemical prophylaxisLovenox/Heparin
• GI prophylaxisPPI
Discharge Planning
• Starts on day 1• Multidisciplinary approach• Talk to family• Stop the “lingo”• Supportive Care consult
• Case manager to discuss insurance
• Document appropriately• Advocate for patient• Team rounding• Team meetings• Monthly M&M• Get hospital
administration involved
Objective 4: Understand management principles for caring for the thermally injured patient
• Higher length of stay• Cost more• Loss of function• Loss of physical freedom• Only 43% geriatric burn patients are transferred to designated burn center
Objective 5: Utilize appropriate resources to maximize outcomes for the
geriatric injured patient• Geriatric trauma unit (G-‐60)– Contained 393 patients (control 280)– Goals: consult trauma service <30 minutes
inpatient room arrival <4 hourstime to OR <36 hoursdischarge within 5 days
– Findings: length of stay; time to OR; overall morbidity and mortality
Mangram, Mitchell, Shif f lett, Lorenzo, Truitt, Goel, Lyons, Nichols, & Dunn, 2012
Geriatric Trauma Unit• Early mobilization• Communication • Weekly Teaching Rounds
• Dedicated SS• Dedicated CM• Commitment to goals
• Experienced nurses• Availability of team• Low patient ratio• Telemetry
• Universal documentation• Continuity of care• Communication boards• Business cards• Family meetings• Night nurse leave notes
• Anesthesia NP• IM consult • Head to toe assessment
• Monthly M&M• Understand fragility of population
Fall Prevention Course
9/7/15
10
Preoperative Checklist Case Studies
Summary
• Fastest growing age group• Expect increase in trauma admissions and cost• Altered compensation to stress of trauma• Ground level falls are not benign• Consider triage to designated trauma center• Concentrate on head to toe examination• Thermally injured have increased M&M• GTU helps maximize outcomes and help patients return to productive lifestyle and independence
Contact infoKara Jones MSN, RN, FNP-‐BCNurse Practitioner Trauma/General SurgeryFaculty Associate Texas Tech University Health Sciences Center School of Medicine
UMC Health System602 Indiana AvenueLubbock, TX 79413O: 807-‐775-‐9315Pg: 806-‐765-‐[email protected]
Jenna Kesesy, MSN, RN, FNP-‐BC, CWSNurse Practitioner Timothy J. Harnar Burn CenterFaculty Associate Texas Tech University Health Sciences Center School of Medicine
References• Ambrose, A.F., Cruz, L., & Paul, G. (2015) “Fall and fractures: A systematic approach to screening
and prevention. “ Maturitis 82(1): 85-‐93.• American College of Surgeons, Committee on Trauma. Resources for the Optimal Care of the
Injured Patient: 2014. Chicago, IL: 2014: 1-‐215.• American College of Surgeons Committee on Trauma. ACS TQIP Geriatric Trauma Management
Guidelines. 2014. Chicago, IL: 2014:1-‐31• American College of Surgeons. (2015) Alcohol Screening and Brief Intervention (SBI) for Trauma
Patients. Chicago, IL. 1-‐15.• www.americangeriatrics.org. Identifying Medications that Older Adults Should Avoid or Use With
Caution: the 2012 American Geriatrics SocietyUpdated Beers Criteria • Avin, K., Hanke, T., Kirk-‐Sanchez, N., McDonough, C., Shubert, T., Hardage, J., & Hartley, G., (2015)
Management of falls in community dwelling older adults: Clinical guidance statement from the academy of geriatric physical therapy of the american physical therapy association. Physical Therapy 95(6) : 815-‐834.
• Ayoung-‐Chee, P., McIntyre, L., Ebel, B., Mack, C., McCormick, W., & Maier, R. (2014). “Long-‐term outcomes of ground-‐level falls in the elderly.” Journal of Trauma and Acute Care Surgery 76(2): 498-‐503.
• Bulger, E.M., Arneson, M.A., Mock, C.N., & Jurkovich, G.J. (2000) “Rib fractures in the elderly.” The Journal of Trauma: Injury, Infection, and Critical Care. 48(6): 1040-‐1047
References• www.aoa.acl.gov “Aging Statis tics”. US Department of Health and Human Services . Adminis tration on
Aging. Adminis tration for community living.• www.census .gov “The Older Population: 2010” 2010 census briefs .• www.cdc.gov“Leading causes of death” number of deaths for leading causes of death• Chen, S., Shi, L., Liang, F., Xu, L., Des is lava, D., Wu, Q., & Zhang, J. (2015) “Exogenous melatonin for
delirium prevention: A meta-‐analys is of randomized controlled trials .” Molecular Neurobiology. • Dela’O, C., Miller, A., Rodriguez , A., Dumire, R., Zipf, J. “The Geriatric Trauma Institute (GTI): The Efficacy of
a Dedicated Geriatric Trauma Service: A Pilot Study. Pts f.org• Gelbard, R., Inaba, K., Okoye, O., Morrell, M., Saadi, Z., Lam, L., Talving, P., & Demetriades , D. (2014). “Falls
in the elderly: a modern look at an old problem.” The American Journal of Surgery. 208:249-‐253.• González-‐Reimers , E., Santolaria-‐Fernández , F., Martín-‐González , M. C., Fernández-‐Rodríguez , C. M., &
Quintero-‐Platt, G . (2014). Alcoholism: A systemic proinflammatory condition. World Journal of Gastroenterology : WJG , 20(40), 14660–14671.
• Helmerhorst, H. J. F., Schultz , M. J., van der Voort, P. H. J., de Jonge, E., & van Westerloo, D. J. (2015). Bench-‐to-‐beds ide review: the effects of hyperoxia during critical illness . Critical Care, 19(1), 284.
• , Howells , G .A., Junn, F.S., Bair, H.A., Bendick, P.J., & Janczyk, R.J. (2005) “Rapid Warfarin Reversal in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Reduces Hemorrhage Progress ion and Mortality.” Journal of Trauma-‐Injury Infection & Critical Care. 59(5):1131-‐1139.
• Ivascu, F. A. Horst, H., Obeid, F., Sorensen, V., & Bivins , B. (1986). “Factors influencing survival of elderly trauma patients .” Critical Care Medicine 14(8): 681-‐684.
“Practice management guidelines for geriatric trauma: The EAST practice management guidelines work group.” The Journal of Trauma: Injury, Infection, and Critical Care. 54:391-‐416.
• Kozar, R., Arbabi, S., Stein, D., Shackford, S., Barraco, R., Biffl, W., Brasel, K., Cooper, Z., Fakhry, S., Livingston, D., Moore, F., & Luchette, F. (2015) “Injury in aged: Geriatric trauma care at the crossroads .” Journal of Trauma and Acute Care Surgery. 78(6): 1197-‐1209.
• Mangram, A.J., Mitchell, C.D., Shifflett,V.K., Lorenzo, M., Truitt, M.S., Goel, A., Lyons , M.A., N ichols , D.J., & Dunn, E.L. (2012) “Geriatric trauma service: A one-‐year experience.” Journal of Trauma and Acute Care Surgery. 72(1):119-‐122, January 2012.
• March, P. & Buckley, L. (2014). “Burns in older adults : Quick lesson.” Published by Cinahl Information Systems. • O’Neal-‐Moffitt, G ., Delic, V., Bradshaw, P.C., & Olcese, J. (2015) “Prophylactic melatonin s ignificantly reduces
alzheimer’s neuropathy and associated cognitive deficits independent of antioxidant pathways in ABPP/PS1 mice.” Molecular Neurodegeneration. 10:27.
• Oreskovich, M., Howard, J., Copass , M., Carrico, C. (1984). “Geriatric trauma: injury patterns and outcome.”Journalof Trauma 24(7): 565-‐572.
• Richards, W.T., Richards, W.A., Miggins, M., Liu, H., Mozingo, D.W. & Ang, D.N. (2013). “Predicting resource utilization of elderly burn patients in the baby boomer era.” The American Journal of Surgery. 2013(205): 29-‐34.
• Romanowski, K.S., Barsun, A., Pamlierri, T.L., Greenhalgh, D.G., & Sen, S. (2014) “Frailty score on admission predicts outcomes in elderly burn injury.” Journal of Burn Care & Research. 36(1): 1-‐6.
blunt multiple trauma: Improved survival with early invasive monitoring.” The Journal of Trauma 30(2) : 129-‐136.
• Solanki, N.S., Greenwood, J.E., Mackie, I.P., Kavanagh,S., & Penhall, R. (2011) “Social issues prolong elderly burn patient hospitalization.” Journal of Burn Care & Research. 32(3) : 387-‐391.
• Stassen, N.A., Lukan, J.K., Mizuguchi, N.N., Spain, D.A., Carrillo, E.H., & Polk, H.C. (2001). “Thermal injury in the elderly: When is comfort care the right choice?” The American Surgeon. 67:704-‐708.
• Sullivan, M.P., Baldwin, K.D., Donegan, D.J., Mehta, S., & Ahn, J. (2014). “Geriatric fractures about the hip: Divergent patterns in the proximal femur, acetabulum, and pelvis.” Orthopedics 37(3) : 151-‐157.