Trainee Advanced Clinical Practitioner Diary- Day 19 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 19

The Emergency Department is one of the biggest Elderly Care departments in the hospital, and it is not well designed to look after them. In the US patients 65 years and older represented 40% of hospitalised adults but compromise less than 13% of the population.

Problems with movement of patients, tethering devices (IV lines, urinary catheters etc.), positioning of the elderly, sensory deprivation, skin care can increase their risk of what might already be a confused state leading to greater problems for them. Hazards of hospitalization of the elderly Ann Intern Med 1993.

Due to their possible multiple co-morbidities and complicated social situation it can often take longer to assess the elderly compared to the younger patient.

Older patients also have a longer average length of stay. US data confirms this and it would be reasonable to be able to expect the same in the UK.  National Hospital Discharge Survey 2005 CDC 2007. They are more prone to chronic illnesses with all the implications for their care that may have. Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden. AM J Public Health 2008

Common problems with elderly patients in hospital can be:

There can sometimes be family pressure to admit to hospital- lack of awareness of the implications of risks of admission versus discharge.

Other difficulties when caring for the elderly patient can include:

Anatomic differences from the adult include:

child_airway2

  • Large head, short neck and prominent occiput.
  • Tongue is relatively large.
  • Larynx is high and anterior.
  • Neonates are nose breathers
  • Airway is funnel shaped. Trauma to the airway easily results in oedema.
  • Chest wall more compliant and breathing is primarily diaphragmatic.
  • Larger surface area to wight ratio.
  • Growth plates not fused

Physiological differences include:

  • Higher heart rate and respiratory rate.
  • Higher metabolic rate
  • Prone to different infections
  • Inclined to deteriorate/improve more rapidly.
  • Different nutrition/fluids needs

Cognitively there will be differences, it may be harder to get a history depending on their age. they may have a much reduced understanding. Child is more prone to be frightened and you have to take into account competence.

Need to be aware of some of the developmental milestones. TrackChildsDevMilestonesEng_Page_2

Emotionally the child might be more labile, influenced by previous experiences and the emotional state could indicate disease/psychological issues. The parents also have to be considered when dealing with the emotional part of the assessment.

Assessment

ABCDE and glucose.

Undress, do not PR or PV.

Always remember ENT

Document rashes carefully

A & B

Effort-

  • Position
  • Respiratory rate
  • Accessory muscles
  • Nasal flaring

Efficacy-

  • Chest expansion
  • Air entry
  • Oximetry

C

Colour, central and peripheral

Capillary refill time

Pulse-

  • Babies- brachial
  • Femorals
  • Radial- older children

Hypotension is a pre morbid sign in children.

D

AVPU, GCS

Posture- decorticate, decerebate

Pupils

E

Temperature

Rashes

Bruising

Spotting The Sick Child (.com)

  

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