Detailed Lesson Plan
Chapter 39
Geriatrics
215–230 minutes
Chapter 39 objectives can be found in an accompanying folder.These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. /
Minutes / Content Outline / Master Teaching Notes /
5 / I. Introduction
A. During this lesson, students will learn about physiological changes, special assessment concerns, and emergency care considerations for geriatric patients.
B. Case Study
1. Present The Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed. / Case Study Discussion
· What can you do to ensure good communication with Mrs. Vaughn?
· What are common causes of breathing difficulties in the elderly?
10 / II. Effects of Aging on Body Systems—The Cardiovascular System
A. People are living longer with chronic illnesses (constituting a larger percentage of an EMT’s patient volume.
B. The aging body has fewer reserves with which to combat diseases and decreased efficiency of compensatory mechanisms, leading to the incidence of acute medical and traumatic emergencies.
C. With age, calcium is progressively deposited in areas of deterioration, especially around the valves of the heart.
1. Stenosis (narrowing) of the valve opening
2. Regurgitation (backward flow of blood)
D. Walls of the heart become generally thickened without any increase in the size of the atrial or ventricular chambers (cardiac hypertrophy).
1. Decreases stroke volume of the heart
2. Decreases the efficiency of the body’s compensatory mechanisms in the face of stress that may be brought about by illness or injury
E. Older patients generally have higher resting heart rates than younger people; however, older hearts have less ability to raise their rate to meet an increased demand from physical activity, stress, or illness.
F. Dysrhythmias, irregular contractions of the myocardium secondary to electrical disturbances in the heart, also deteriorate cardiac output in the geriatric patient.
G. Arteries lose their elasticity, creating greater resistance against which the heart must pump to maintain adequate blood flow.
H. Arteriorsclerosis tends to occur with age, further increasing pressure the heart must pump against.
I. A drop in baroreceptor sensitivity often leads to orthostatic hypotension, a drop in systolic pressure and elevation in the heart rate when the patient goes from a lying to a standing position. / Teaching Tip
Generate discussion by asking students what they think of when they think of the elderly.
Class Activity
Have students write a paragraph describing how they envision themselves and their lives when they are 70 years old. Students can read the thoughts aloud to the class to generate discussion.
Discussion Questions
· What are the effects of aging on the heart valves? How do these changes affect cardiac output?
· What are the effects of arteriosclerosis?
Critical Thinking Discussion
· How would you expect the aging process to affect an elderly patient’s response to blood loss?
· How might it change the signs and symptoms associated with shock?
Weblinks
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access web resources on aging hearts and arteries and hypertension.
5 / III. Effects of Aging on Body Systems—The Respiratory System
A. Muscles used for respiration decrease in size and strength.
B. Rib cage becomes less pliable.
C. Decline in diffusion of oxygen and carbon dioxide across the alveolar membrane as alveolar surfaces decrease
D. Chemoreceptors in the aortic arch become less sensitive (failing to detect hypoxia or hypercapnea).
E. Decrease in the number and strength of smooth muscle fibers that support smaller airways, diminishing airflow to the terminal alveoli during inspiration and possibly trapping exhalation
F. Airflow velocity diminishes after 30.
G. The ability of the lungs to inhibit or resist disease and infection is also diminished with age. / Discussion Question
How does aging affect the respiratory system?
10 / IV. Effects of Aging on Body Systems—The Neurological System
A. Decrease in the mass and weight of the brain, increasing the amount of cerebral spinal fluid that occupies extra space in the skull
B. Overall ability of the brain to operate becomes impaired by plaques and tangles.
C. Nerve cells degenerate, causing slowing of reflexes and difficulty sensing body position.
D. Ability to perceive hunger and thirst is altered.
E. Ability of the brain to regulate vital functions may not operate with efficiency during stressful times.
F. Sensory perception (sight, hearing, touch, smell, pain) tends to diminish.
1. Diseases affecting sight
a. Cataracts
b. Glaucoma
c. Macular degeneration
d. Retinal detachment
2. Presbycusus (age-related hearing loss) is most marked at higher frequencies; remember that elderly patients may have/be wearing a hearing aid.
G. Neuropathy is any derangement or abnormal function of the motor, sensory, and autonomic nerve tracts (pain, numbness, tingling, swelling, absent pain perception) and may further complicate presentation of findings characteristic to a particular problem. / Discussion Question
How does aging affect the nervous system? What are the consequences of these changes?
Teaching Tip
Alter several pairs of cheap glasses to mimic age-related vision changes. Assign students to perform various tasks, such as reading aloud from the textbook.
5 / V. Effects of Aging on Body Systems—The Gastrointestinal System
A. Reduction in food enjoyment due to sensory loss (taste, smell)
B. Deterioration of structures in the mouth and drop in salivary flow
C. Chronic heartburn from muscle tone loss in the stomach and esophagus
D. Decrease in liver’s in size, weight, and function
E. Food takes longer to move through the system due to slowing smooth muscle contractions in the gastrointestinal tract.
F. Nutrients are not as readily absorbed (small intestine), and fecal impaction and constipation are common (large intestine).
G. Degeneration of the sphincter muscle can cause loss of bowel control.
5 / VI. Effects of Aging on Body Systems—The Endocrine System
A. Changes in the endocrine system may have no noticeable effect on overall health, with the exception of increasing the risk of some health problems (Type II diabetes).
B. Changes that can lead to hypertension and orthostatic hypotension
1. Increase in the levels of hormones that increase blood pressure
2. Derangement of hormones that regulate fluid balance
3. Decrease in target organ response to beta (sympathetic) stimulation in the heart
C. Mild carbohydrate intolerance and a minimal increase in fasting blood glucose levels (drop in receptor cell responsiveness to insulin)
D. Increased serum level of atrial natriuretic hormone, leading to fluid imbalance
E. Decrease in metabolism of thyroxine, leading to decreased conversion into triiodothyronine and affecting body temperature, growth, and heat rate / Weblink
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access a web resource on healthy aging.
5 / VII. Effects of Aging on Body Systems—The Musculoskeletal System
A. Osteoporosis makes bones more brittle and susceptible to fractures and slows the healing process.
B. Kyphosis is the characteristic curvature of the spine seen in many elderly patients and results when the disks located between the vertebrae of the spine start to narrow.
C. Joints begin to lose their flexibility, and ligaments begin to lose their strength.
D. Elderly experience progressive loss of skeletal muscle mass. / Weblinks
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access web resources on balance problems in the elderly and frailty and aging.
5 / VIII. Effects of Aging on Body Systems—The Renal System
A. Kidneys become smaller in size and weight due to loss of nephrons (less surface area to filter blood).
B. Changes in the cardiovascular system result in a drop in renal blood flow (less blood passing through the kidneys for filtration).
C. Kidney malfunction or injury can lead to disturbance in fluid balance and electrolyte distribution.
D. Drug toxicity is more likely to occur.
5 / IX. Effects of Aging on Body Systems—The Integumentary System
A. Skin becomes thinner, and there is less attachment tissue between the dermis (inner layer) and epidermis (outer layer).
B. Skin is much more prone to injury and takes longer to heal.
C. Less perspiration is produced, and sense of touch is dulled.
D. Diminished effectiveness of the skin as a protective barrier / Knowledge Application
Students should be able to integrate knowledge of age-related physiological changes into the assessment and management of elderly patients.
15 / X. Special Geriatric Assessment Findings—Assessment Finding: Chest Pain or Absence of Chest Pain
A. Heart attack (myocardial infarction)
1. Geriatric patients may experience a “silent heart attack”—Patient may have no, or very little, chest discomfort.
2. Common symptoms may be very general (e.g., weakness, fatigue, confusion, syncope).
3. Look for nitroglycerin at the scene.
4. Emergency medical care
a. Administer high-flow, high concentration oxygen.
b. Administer nitroglycerin as appropriate in consultation with medical direction.
c. Transport the patient expeditiously.
B. Congestive heart failure
1. May have acute or chronic onset
2. Caused by a heart that becomes weakened over time as a result of the changes in ages, hypertension, arteriosclerotic disease, and heart valve damage.
3. A “backup” in the peripheral blood vessels and vessels in the lungs causes fluid to leak out of the vessels.
a. Assessment findings
b. Jugular vein distention,
c. Altered mental status,
d. Fatigue
e. Crackling
f. Wheezing
g. Dyspnea
h. Orthopnea,
i. Tachypnea
j. Chest pain
k. Anxiety
4. Emergency medical care
a. Administer high-flow, high-concentration oxygen.
b. Place the patient in the Fowler’s position.
c. Expedite transport and be prepared to ventilate. / Teaching Tip
Assign small groups of students to each of the topics in the section. Give students 20 to 30 minutes to research their topic before presenting it to the class. Be prepared to correct misconceptions and fill in gaps.
Discussion Questions
· How is the presentation of the elderly patient with a heart attack often different from that of younger patients?
· What is the relationship between aging and congestive heart failure?
20 / XI. Special Geriatric Assessment Findings—Assessment Finding: Shortness of Breath (Dyspnea)
A. One of the most common complaints in the elderly
B. Remember that any additional burden to an already diminished respiratory function can lead to inadequate breathing.
C. Pulmonary edema
1. Fluid in the lungs, resulting in inadequate gas exchange and respiratory distress
2. Gradual or sudden onset that can result in death if care is not provided
3. Causes include CHF, heart attack, or valve damage
4. Assessment findings
a. Severe respiratory distress (orthopnea)
b. Altered mental status,
c. Coughing with possibly blood-tinged sputum
d. Other signs of CHF
5. Emergency medical care
a. Administer oxygen at 15 lpm by nonrebreather mask (or positive pressure ventilation, if necessary).
b. Place the patient in a Fowler’s position.
c. Monitor for inadequate breathing.
d. Transport expeditiously.
D. Pulmonary embolism
1. Blockage in the arteries of the lungs
2. Very sudden onset with localized chest discomfort
3. Usually occurs when a blood clot (embolism) breaks free from veins of the lower extremities or pelvis
4. Signs and symptoms may include hypotension, localized wheezing, and low pulse oximeter reading.
5. If a large embolism occludes more than half of the pulmonary circulation, rapid death can result.
6. Predisposing factors
a. Aging
b. Smoking
c. Cancer
d. Fractures of large bones
e. Major surgery
f. Existing cardiovascular disease
g. Prolonged bed rest
h. Trauma
7. Emergency medical care
a. Administer oxygen and monitor for inadequate breathing.
b. Provide positive pressure ventilation (if necessary).
c. Transport the patient rapidly to the hospital.
E. Pneumonia
1. Infection of the lungs caused by bacterium, virus, or other pathogen
2. Aspiration pneumonia often results from accidental aspiration of food or vomitus into the lungs.
3. Tendency to strike with following multiple factors
a. Advancing age
b. Bed ridden at home or institutionalized
c. Immune system compromise
d. History of other pulmonary diseases
e. Cancer
f. History of inhaled toxins
4. Common symptoms in the elderly (may not present with common symptoms for younger patient)
a. Increased respiration rate
b. Progressive worsening of dyspnea
c. Dyspnea with exertion
d. Congestion (with or without chills)
e. Cough with some sputum
f. Wheezing
g. Malaise
h. Altered mental status
i. Inadequate breathing (severe)
j. Hypotension (severe)
k. Dehydration (severe)
l. Dull sounds upon percussion (severe)
m. Increased vocal fremitus (severe)
5. Emergency medical care
a. Maintain the patient’s airway.
b. Administer high-flow, high-concentration oxygen.
c. Transport the patient in a Fowler’s position or position of comfort.
d. If breathing is inadequate, provide oxygen via positive pressure ventilation.
F. Chronic obstructive pulmonary disease
1. Disease complex that includes number of individual pulmonary disease processes that result from gradual deterioration of the pulmonary structures
2. Patient may complain of respiratory distress, use accessory muscles, or be on a home oxygen unit.
3. Emergency medical care
a. Administer oxygen at 15 lpm by nonrebreather mask if breathing is adequate.
b. Provide positive pressure ventilation with supplemental oxygen if breathing is inadequate.
c. Assist with administering prescribed metered-dose inhaler if approved by medical direction.
d. Transport the patient in a position of comfort (Fowler’s). / Discussion Question
What are some causes of shortness of breath in elderly patients?
35 / XII. Special Geriatric Assessment Findings—Assessment Finding: Altered Mental Status
A. Never assume that a patient’s altered mental status is “normal” for him or that it is “senility”. (Family members may help provide information.)
B. Stroke
1. Blood vessel in the brain becomes blocked by a clot, obstructing blood flow, or ruptures and allows blood to accumulate in the brain tissue itself.
2. Intracranial pressure sharply increases, carbon dioxide increases, and nerve cells in the brain start to die.