Avoid dangerous errors in elderly trauma cases
Could mistakes made in your ED cause an injured elderly patient to go into fluid overload or become hypothermic? Common errors in nursing practice can be life-threatening for these patients, says Karen Hayes, PhD, ARNP, assistant professor at the School of Nursing at Wichita (KS) State University.
During the past decade, ED use by elderly patients has increased significantly, with 61 visits for every 100 persons 75 years or older, compared with 39 visits per 100 people for the general population. In 2002, patients ages 65 or older made more than 16 million ED visits, comprising 15% of all visits.1
To improve care of elderly trauma patients, make the following practice changes:
• Record and monitor intake and output.
Fluid or volume overload can be very dangerous for the older trauma patient, warns Jean M. Marso, BSN, RN, trauma coordinator at University of Colorado Hospital in Denver. "If these patients have a central line placed in the ED that is capable of monitoring the patient’s central venous pressure [CVP], ED nurses can and should perform CVP recordings," she says. "Measuring a CVP is not an invasive procedure and doesn’t need a physician’s order."
Document all intake, including intravenous (IV) fluids, blood products, oral computerized tomography contrast, and oral intake, with hourly urine output recorded using a urimeter, says Marso. Having a record of your patient’s intake is valuable information to prevent fluid overload, which can result in acute respiratory distress syndrome and electrolyte imbalances, she explains.
"Trending of your patient’s urine output lets you know if what you are putting in is coming out," Marso advises. "If it is not coming out, then you need to evaluate if your patient is fluid overloaded by listening to lung and heart sounds, checking for scleral or orbital edema, and measuring CVP."
If urine output is lower than expected, blood pressure or CVP remains low, or there is persistent tachycardia, the patient may require additional fluid resuscitation, she says. "This is especially important in the burn trauma patient," adds Marso.
• Don’t overlook a patient’s lab values.
Lab results tell you about your patient’s renal function, volume status, and coagulation status to determine the need for fluid resuscitation, says Marso. "Nurses are good at making sure that labs get sent, but often we rely on the physician to check the results. We assume the physician will inform us in a timely manner if there are abnormal values," says Marso. "Make it routine to know the results of all labs that are ordered."
University of Colorado’s ED uses a computerized system for notification of lab results so lab values can be seen at a glance, says Marso. "We have an electronic tracking board on all patient care computer screens that alerts us when lab results are available. The screen is flagged if the results are abnormal," she says.
• Avoid leaving trauma patients exposed.
Older trauma patients are especially susceptible to hypothermia, says Marso. "We are taught to expose the patient completely to assess for all injuries, but often we leave them exposed," she says. "Keep the patient covered, and use warm fluids and blood products during fluid resuscitation."
Use a blanket to expose one portion of the patient at a time, and view only the area that is necessary for assessment or a procedure, says Marso. "For example, when inserting a Foley catheter, only the perineum or groin needs to be exposed. The chest, arms, and legs can be covered or wrapped in blankets," she says.
• Obtain a complete medication history.
If you are unaware of the medications patients are taking, this could have a devastating impact on their outcome, warns Hayes. "The primary care provider is the best source of accurate history if a recent hospital chart is not available," she says. "Another accurate source for medications is the filling pharmacy. Elders tend to use one pharmacist, unlike younger people."
Medications can dramatically impact the care an elderly trauma patient receives, as follows, Hayes adds:
— Antiplatelets can cause bleeding. The patient will need to be watched closely for changes in vital signs indicative of shock, and the patient may need reversal agents such as vitamin K, says Hayes.
— Beta-blockers can cause hypotension and bradycardia, with patients unable to respond to shock. Beta-blockers can be overcome with agents such as atropine and volume-expanding fluids, says Hayes. "Isoproterenol and epinephrine may be necessary to overcome the beta blockade in a shock patient," she adds.
— Diuretics may cause electrolyte abnormality and worsen hypovolemia. "Fluid volume replacement must be closely monitored, as the patient may have more deficit than expected and therefore may need more fluids to get an effect," says Hayes.
Reference
- McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary: Advance Data from Vital and Health Statistics No. 340. Hyattsville, MD: National Center for Health Statistics; 2004.
Sources
For more information on caring for elderly trauma patients in the ED, contact:
- Karen Hayes, PhD, ARNP, Assistant Professor, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260. Phone: (316) 978-5721. E-mail: [email protected].
- Jean M. Marso, BSN, RN, Trauma Coordinator, University of Colorado Hospital, 4200 E. Ninth Ave., Mail Stop A021-630, Denver, CO 80262. Phone: (303) 372-8905. Fax: (303) 372-0267. E-mail: [email protected].
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