Download Chapter 39

MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 39
Geriatrics
215–230 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
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
I.
5
10
Master Teaching Notes
Introduction
Case Study Discussion
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.
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.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39

What can you do to ensure good
communication with Mrs. Vaughn?
 What are common causes of breathing
difficulties in the elderly?
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
PAGE 1
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
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.
5
10
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.
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
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
Discussion Question
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
How does aging affect the respiratory
system?
How does aging affect the nervous system?
What are the consequences of these
changes?
PAGE 2
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
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.
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5
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.
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.
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
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
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.
PAGE 3
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
5
5
5
15
Content Outline
Master Teaching Notes
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.
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.
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
X. Special Geriatric Assessment Findings—Assessment Finding:
Teaching Tip
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.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Students should be able to integrate
knowledge of age-related physiological
changes into the assessment and
management of elderly patients.
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.
PAGE 4
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
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.
XI. Special Geriatric Assessment Findings—Assessment Finding:
20
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
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
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?
Discussion Question
What are some causes of shortness of
breath in elderly patients?
PAGE 5
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
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
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
PAGE 6
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
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.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
PAGE 7
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
c. Assist with administering prescribed metered-dose inhaler if
approved by medical direction.
d. Transport the patient in a position of comfort (Fowler’s).
XII. Special Geriatric Assessment Findings—Assessment Finding:
35
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.
3. Signs and symptoms
a. Inequality of pupils
b. Slurred speech or abnormal speech patterns
c. Headache
d. Memory disorders
e. Alterations in the respiratory pattern
f. Rapid, or abnormally slow, heart rate
g. High systolic pressure which gradually becomes normal or
hypotensive
h. Possible seizures
i. Nausea or vomiting
j. Muscle weakness or paralysis
k. Sensory loss
4. Emergency medical care
a. Recognition, aggressive oxygenation, and ventilation
b. Maintain patent airway.
c. Transport in a Fowler’s position or lateral recumbent position (if
unresponsive).
C. Transient ischemic attack (TIA)
1. Similar in presentation to a stroke, but the signs and symptoms are
completely reversed within 24 hours of onset, usually sooner.
2. Occurs when blood supply to an area of the brain is temporarily
occluded, causing a malfunction of brain tissue that is not being
perfused
3. Treatment steps are the same as for a stroke.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Discussion Question
What are some causes of altered mental
status in elderly patients?
PAGE 8
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
D. Seizure
1. Sudden and temporary alteration in the mental status caused by
massive electrical discharge in a group of nerve cells in the brain
2. Common causes
a. Cardiac arrest
b. Low blood sugar
c. Tumors
d. Head trauma
e. Stroke/TIA
f. Infections
g. Electrolyte imbalance from kidney problems
3. Emergency medical care
a. Do not physically restrain the patient while he is actively seizing.
b. Monitor the airway and suction as necessary.
c. Administer oxygen at 15 lpm by nonrebreather mask (if breathing is
adequate) or positive pressure ventilation (if breathing is
inadequate).
d. Place patient in recovery position to help prevent aspiration (if
unresponsive).
E. Syncope
1. Temporary loss of responsiveness that usually reverses once the patient
is lying down
2. Caused by a reduced blood flow to the brain and can be a sign of a
number of underlying diseases as well as side effects or even strong
emotion
3. Emergency medical care
a. Ensure an adequate airway.
b. Provide high-flow, high-concentration oxygen by a nonrebreather
mask or with positive pressure ventilation.
c. Place the patient in recovery position (if unresponsive).
d. If patient suffered a fall, fully immobilize him as a precautionary
measure.
F. Hyperosmolar hyperglycemic nonketotic syndrome
1. Diabetic condition in which the blood glucose level elevates because of
inadequate insulin secretion or action on target cells; however, enough
insulin is secreted to keep mass amounts of fat from being metabolized
for energy.
2. Glucose level does not raise high enough to cause excessive urination
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
PAGE 9
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
from osmotic diuresis, causing severe dehydration.
3. Signs and symptoms
a. Altered mental status (gradual onset)
b. History of diabetes
c. Elevated glucose level
d. Polydipsia
e. Polyuria
f. Dry oral mucous membranes
g. Dizziness
h. Confusion
i. Seizures
j. Significant dehydration
4. May be the first indication of a diabetic condition
5. Check the blood glucose level in any patient who presents with signs of
excessive urination, thirst, or dehydration.
6. Emergency medical care
a. Protect the airway.
b. Provide supplemental oxygen (or positive pressure ventilation if
patient is breathing inadequately).
c. Provide circulatory support.
d. Consider ALS intercept during transport to the hospital.
G. Drug toxicity
1. Adverse or toxic reaction to a drug or drugs
2. Elderly are at greater risk since they tend to have a number of coexisting
diseases.
3. Emergency medical care
a. Figure out how the drug is affecting the patient’s airway, breathing,
and circulation status.
b. Maintain airway and oxygenation, and prevent aspiration.
c. If possible, take all medications found on the patient or at the scene
to the hospital with the patient.
H. Dementia and delirium
1. Dementia is a condition resulting from malfunctioning of normal brain
activity
a. Chronic, irreversible condition that can be severely worsened by
infection, medication change, trauma, or other acute condition.
b. Signs and symptoms
i. Chronic changes in cognition, loss of short-term memory
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Discussion Question
Why are the elderly more prone to drug
toxicity?
PAGE 10
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
I.
Master Teaching Notes
ii. Decline in intellectual abilities
iii. Decline in judgment, math abilities, and abstract thought
iv. Anger
c. May be caused by some medications (analgesics, sedatives),
diseases (heart disease, Huntington’s chorea), visual and auditory
problems, strokes, brain trauma or tumors, alcohol use, and so on
d. Emergency medical care—Includes oxygen, positioning, and
transport to the hospital
2. Delirium is an alteration in mental status but presents with more recent
and sudden onset.
a. Patient may have a history with a delirium episode (e.g., sedative
use, fever, infectious medical condition).
b. Signs and symptoms
i. Faster onset
ii. Disjointed (nonsensical) thought processes
iii. Incoherent speech
iv. Declines in mental status
v. Increased or decreased psychomotor activity
c. Additional physical findings will reflect the underlying pathology that
is causing the delirium.
d. Emergency medical care—Includes oxygen, positioning, protection
from injury, and transportation to the hospital. If delirium is caused
by a reversible cause the EMT can treat (e.g., low blood sugar),
provide specific management for that condition.
3. Use patient history (from family member or primary care provider) to
differentiate between delirium and dementia.
Alzheimer’s disease
1. Causes patients to stop eating, become immobile, and be subject to
numerous infections that can lead to death
2. Signs and symptoms
a. Confusion
b. Emotional depression
c. Irritability
d. Violence between lucid intervals
e. Progressive loss of appetite
f. Decreasing ability for patient to care for his own needs
g. Childlike behavior (late stages)
3. Emergency medical care
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Discussion Question
What are some characteristics of
Alzheimer’s disease?
Video Clip
Go to www.bradybooks.com and click on
PAGE 11
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
a. Establish and maintain airway, breathing, and circulatory status.
b. Remember that acts of aggression are not against you personally
but rather a symptom of the disease.
XIII. Special Geriatric Assessment Findings—Assessment Finding:
15
Signs of Trauma or Shock
A. Most common trauma is blunt trauma from falls, motor vehicle crashes, and
pedestrians struck by automobiles.
B. Reasons for blunt trauma
1. Altered mental status
2. Slower reflexes
3. Failing eyesight and hearing
4. Medication effects
5. Activities that exceed physical limitations
6. Arthritis
7. Blood vessels that are less elastic and more subject to injury
8. Fragile tissues, brittle bones, and stiffer joints
9. General loss in muscle tone and strength
C. Both environmental (e.g., steep steps, slipping rugs) and medical reasons
(e.g., low blood pressure, dizziness) for falls; determine the cause.
D. Assess for the following.
1. Hip fracture
2. Head injury (may take days or weeks to develop)
3. Chest and abdominal injury
4. Spine fractures
5. Fractures of the hand, wrist, forearm, or shoulder
E. Shock progresses much more rapidly in the elderly than in any other age
group. Organs cannot tolerate periods of hypoperfusion.
F. Emergency medical care
1. Stabilize the spine during the primary assessment.
2. Administer high-flow, high-concentration oxygen.
3. Provide positive pressure ventilation if the patient is breathing
inadequately.
4. Regard any signs of poor perfusion as signs of serious trauma and
transport the patient as rapidly as possible.
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on
Alzheimer’s disease.
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a web resource
on seniors’ health.
XIV. Special Geriatric Assessment Findings—Assessment Finding:
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
PAGE 12
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
15
Content Outline
Master Teaching Notes
Gastrointestinal Bleeding
A. May occur anywhere along the digestive tract and may be obvious or occult
B. Sign that some gastrointestinal disease is present but is not a disease itself
C. Findings that support the field impression of GI bleeding in an elderly patient
1. Hemetemisis
2. Hematochezia
3. Melena
4. Dyspepsia
5. Hepatomegaly
6. Jaundice
7. Constipation or diarrhea
8. Agitation
9. Dizziness
10. Inability to find a comfortable position
11. Shock
12. Peripheral, sacral, and periorbital edema from venous congestion
13. Low-grade fever
14. Respiratory distress and vital sign changes
D. Emergency medical care
1. Ensure patent airway and provide manual or mechanical airway
assistance if patient is unable to protect the airway himself.
2. If breathing is adequate, provide supplemental oxygen; if breathing is
inadequate, provide oxygen via positive pressure ventilation.
3. Keep patient in recovery position if responsive, or supine if unresponsive
or you are maintaining the airway. (Consider volume depletion if blood
pressure is 10 mmHg lower when the patient is standing compared to
lying supine.)
4. Summon ALS intercept while you expedite transport to the hospital.
XV. Special Geriatric Assessment Findings—Assessment Finding:
10
Environmental Temperature Extremes
A. Be acutely aware of any extremes in the ambient air temperature to which
the patient has been subjected.
B. Hypothermia—A body temperature less than 35 degrees Celsius (95
degrees Fahrenheit)
1. Factors making the elderly more prone to hypothermia include smaller
insulating layer of fat, impaired reflexes and limited movement, slowing
metabolic rate, reduced muscle mass, decreasing blood flow, reduced
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Discussion Question
What are some factors that make the
elderly more prone to environmental
emergencies?
PAGE 13
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
shivering response, and limited income preventing the patient from
heating home properly.
2. Emergency medical care includes protecting the airway, maintaining
normal breathing and circulatory status, and removing the patient from
the cold environment (including removing wet clothing).
C. Hyperthermia—Increased body temperature
1. Geriatric’s core temperature can increase more rapidly than the younger
patient’s.
2. To institute prehospital cooling of a hyperthermic geriatric patient, follow
the same guidelines as for treating a younger patient.
XVI. Special Geriatric Assessment Findings—Assessment Finding:
10
Geriatric Abuse
A. Those at risk
1. Cared for by someone under stress from other resources
2. Bedridden
3. Demented
4. Incontinent
5. Frail
6. Disturbed sleep patterns
B. Signs of abuse
1. Bruises
2. Bite marks
3. Bleeding beneath scalp
4. Lacerations on face
5. Trauma to ears
6. Broken bones
7. Deformities to chest
8. Cigarette burns or rope marks
C. Pay attention to inconsistencies when you get your history from the patient.
D. Do not confront the family or care provider with your suspicion.
E. Make your suspicion known to the receiving facility.
F. Follow local protocols or state laws regarding reporting suspected abuse.
5
Discussion Question
What are some indications of abuse of the
geriatric patient?
Knowledge Application
Given several scenarios, students should
be able to identify and manage common
complaints in geriatric patients.
XVII. Assessment-Based Approach: Geriatric Patients
A. Approach the geriatric patient with compassion, concern, and respect.
B. Avoid any of the purposeful or accidental stereotyping of ageism (knowingly
or unknowingly discriminating against people who are old).
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
PAGE 14
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
C. Consider the two greatest social issues: isolation and marital status.
D. Consider that the geriatric patient may have dwindling finances.
E. Geriatric patients may live in independent or dependent living situations
(family member, assisted living, specialty care facility, hospice). Dependent
living situations may create delays in getting to the patient due to locked
doors, privacy gates, and so on.
F. Attempt to get as much of the history as you can from the patient himself.
G. Consider advance directives.
H. Elderly at risk for needing health care
1. Live alone
2. Are incontinent
3. Are immobile
4. Have been recently hospitalized
5. Have been recently bereaved
6. Have an altered mental status
5
5
XVIII. Assessment-Based Approach: Geriatric Patients—Scene Size-Up
A. Determine if there are any safety hazards to yourself, crew, patient, or
bystanders.
B. Take Standard Precautions (gloves and mask).
C. Assess the environmental temperature.
D. Determine if any additional patients are present and call for additional
resources.
E. Determine whether the patient is suffering from trauma or a medical
problem. (Be alert to the fact that the cause of the emergency may be more
complex than is first apparent).
F. Maintain a high index of suspicion and be ready to change your focus of
care as you gather more information during the primary and secondary
assessments.
Teaching Tip
XIX. Assessment-Based Approach: Geriatric Patients—Primary
Discussion Question
Assessment
A. Assess the mental status to determine a baseline level of consciousness
and the possible need for airway protection and ventilatory assistance.
B. Monitor the patient’s airway and breathing, and be prepared to initiate
positive pressure ventilation.
C. Assess central and peripheral pulses, noting the rate, strength, and rhythm.
Initial pulse check should include an assessment of the radial pulse. Note
any irregularity to rhythm.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Ensure that students have ample
opportunities to practice assessment and
management of elderly patients.
Discussion Question
Why is it especially important to assess the
environment of the elderly patient?
What unique considerations should you
keep in mind when assessing the breathing
of an elderly patient?
PAGE 15
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
D. Skin condition and temperature
1. Remember that the geriatric body does not display the same signs and
symptoms of dehydration as in the younger patient.
2. The geriatric patient’s skin may not feel warm even if the geriatric patient
does have an infection.
E. Categorize the patient as stable or unstable. (Err on the side to benefit the
patient and manage him as stable.)
1. Stable—An elderly patient who is alert and has an open airway,
adequate breathing, signs of good peripheral perfusion, and a strong
peripheral pulse
2. Unstable—An elderly patient with an acute change in mental status, an
obstructed airway, inadequate breathing, or signs of poor perfusion (in
need of emergency care during primary assessment)
XX. Assessment-Based Approach: Geriatric Patients—Secondary
15
Assessment
A. Gather the history and conduct your physical exam based on the patient’s
mechanism of injury (if trauma) or chief complaint (if medical).
1. Diminished sight or blindness—Talk calmly and be positioned so that the
patient can best see you if he has any sight at all. Make sure patient is
wearing his eyeglasses if he has them.
2. Diminished hearing or deafness—Do not assume the patient is deaf. If
the patient is wearing a hearing aid, make sure that it is turned on, and
do not shout. Use your stethoscope, lip-reading, or note-writing as
appropriate.
B. For the geriatric trauma patient
1. Note the mechanism of injury.
2. Remember that the severity of pain is unreliable as an indicator of the
seriousness of the injury.
3. Maintain a high index of suspicion and treat any complaint of pain as a
symptom of a serious injury.
4. Examine the head, neck, chest, abdomen, pelvis, extremities, and
posterior body, and inspect and palpate for any evidence of trauma.
5. Assess and record baseline vital signs and obtain a history.
6. In order to treat the entire geriatric patient, you need to perform an entire
physical examination.
C. For the geriatric medical patient
1. Patient may have one or more chronic diseases or medications which
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
Discussion Question
What guidelines should you follow when
interacting with patients with diminished
sight or hearing?
Class Activity
Give pairs of students items needed to
simulate age-related changes. Students
should take turns playing the role of both
the EMT and the patient. Have students
wear the items described for additional
activities to demonstrate some of the
challenges faced by the elderly:
 Attempting to purchase something from
a vending machine
 Trying to determine the color of “pills”
(pastel candies)
 Trying to grasp small “pills” or buttons
 Trying to read medication and
household product labels
PAGE 16
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
can mask or alter the presentation of signs and symptoms.
2. Patient’s memory, hearing, sight, and orientation may be diminished,
making it more difficult to determine chief complaint. However, do not
assume that the patient is this way.
3. Be sure to treat the patient with concern and compassion and talk to the
patient (rather than talk about the patient to others).
4. Points to remember during the physical examination
a. The patient may become fatigued easily.
b. Clearly explain what you are going to do before examining the
patient.
c. The patient may minimize or deny symptoms because he fears
being bedridden, institutionalized, or losing his self-sufficiency.
d. Peripheral pulses may be difficult to evaluate.
e. Distinguish signs and symptoms of chronic problems or natural
aging processes from the signs and symptoms of acute problems.
5. Questions to ask during the history
a. Have you had any trouble breathing?
b. Have you had a cough lately?
c. Have you had any chest pain?
d. Did you get dizzy?
e. Have you fainted?
f. Have you had any headaches lately?
g. Have you been eating and drinking normally?
h. Have there been any changes in your bowel or bladder habits?
i. Have you fallen lately?
6. Address the patient as “Mr.”, “Mrs.” or “Miss”.
7. Be sure to remove clothing as necessary to conduct the physical exam.
8. If patient is unresponsive or has an altered mental status, perform a
physical assessment to find and treat any life threats. Scan the scene for
clues.
9. Collect and transport the patient’s medications.
10. Assess and record the baseline vital signs.
11. Perform a secondary exam on the geriatric medical patient whether he is
alert, has an altered mental status, or is unresponsive.
XXI. Assessment-Based Approach: Geriatric Patients—Emergency
15
What are some ways of demonstrating
respect for elderly patients?
Discussion Questions

Why may elderly patients minimize their
symptoms?
 What are some specific questions that
you should ask when assessing an
elderly medical patient’s complaints?
Knowledge Application
Given several scenarios, students should
be able to identify and manage common
Medical Care and Reassessment
A. Maintain a patent airway (dentures).
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
Critical Thinking Discussion
DETAILED LESSON PLAN 39
PAGE 17
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
B.
C.
D.
E.
Insert an airway, if necessary.
Assess and be prepared to assist ventilations.
Establish and maintain oxygen therapy.
Position the patient.
1. Medical emergency with alert patient who is able to protect his own
airway: comfortable position such as Fowler’s
2. Patient with altered mental status and inability to protect his own airway:
left lateral recumbent position
3. Patient with suspected spine injury: immediate manual stabilization of
the spine followed by immobilization to a long backboard (accommodate
curvature of the spine).
4. Unresponsive patient: immobilize patient fully
F. Transport.
G. Reevaluate the geriatric patient frequently.
1. Every 15 minutes for a stable patient
2. Every five minutes for an unstable patient
10
XXII. Follow-Up
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 39 Summary.
2. Complete Chapter 39 In Review questions.
3. Complete Chapter 39 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 39 quiz
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
complaints in geriatric patients.
Case Study Follow-Up Discussion

What things should you consider
regarding the spouse’s (Mr. Vaughn’s)
needs?
 How can you make Mrs. Vaughn feel
comfortable in your care?
Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix
to the Instructor’s Wraparound Edition.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
PAGE 18
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
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 39
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