2. • The human body changes as we age. These changes necessitate that nurses re-evaluate how they
assess, plan, deliver and evaluate the nursing care they provide to older adults. According to The
American Journal of Nursing (AJN) nurses today will care for more adults over 65 than any other
patient population.
• This specialized care and specific care required by this age group is a skill that many nurses did not
learn in nursing school.
• http://www.nursingcenter.com/lnc/static?pageid=730388
3. Statistics
• The growth in the number and proportion of older adults is unprecedented in the history of the
United States. Two factors—longer life spans and aging baby boomers—will combine to double the
population of Americans aged 65 years or older during the next 25 years to about 72 million. By
2030, older adults will account for roughly 20% of the U.S. population (State of Aging and Health in
America 2013).
• By 2050, it is anticipated that Americans aged 65 or older will number nearly 89 million people, or
more than double the number of older adults in the United States in 2010 (www.cdc.gov/aging).
4. Diversity in aging population
• In 2010, 80% of adults aged 65 years or older in the United States were non-Hispanic white. By
2030, that percentage will have declined, and older non-Hispanic white adults will make up 71.2%
of the population, whereas Hispanics will make up 12%, non-Hispanic blacks nearly 10.3%, and
Asians 5.4%.
• By 2050, the racial and ethnic diversity of older U.S. adults will have changed even more
profoundly. Older non-Hispanic white adults, long deemed the “majority population,” will account
for only about 58% of the total population aged 65 or older, a decline of more than 20% from 2010
5. How diversity affects teletriage
• For a variety of reasons, older adults in these groups may experience the effects of health
disparities more than younger people.
• Language barriers, reduced access to health care, low socioeconomic status, and differing cultural
norms can be major challenges to promoting health in an increasingly diverse older population
6. Leading causes of death in elderly
• Heart disease and cancer pose their greatest risks as people age, as well as stroke, chronic lower
respiratory diseases, Alzheimer’s disease, and diabetes
• Even with the availability of vaccines, Influenza and pneumonia continue to contribute to deaths
among older adults.
7. Chronic illnesses and adl’s
• Chronic diseases can affect a person’s ability to perform even the simplest of activities. At
first, these patients may have trouble with activities such as managing money, shopping,
preparing meals, and taking medications as prescribed. As functional further declines, they
may lose the ability to perform more basic activities such as taking care of bathing, feeding
themselves, getting dressed, and toileting.
• Lack of mobility significantly narrows an older person’s world and ability to do the things that
bring enjoyment and meaning to life. Loss of the ability to care for oneself safely and
appropriately means further loss of independence and can often lead to the need for care in
an institutional setting
8. Cost of growing older
• By 2030, health care spending will increase by 25%,largely because the population will be older.
• This estimate does not take into account inflation and the higher costs of new technologies.
• Medicare spending is projected to increase from $555 billion in 2011 to $903 billion in 2020.
10. Stroke- statistics from cdc.gov 2014
• Stroke kills almost 130,000 Americans each year—that’s 1 out of every 19 deaths.
• On average, one American dies from stroke every 4 minutes.
• Every year, more than 795,000 people in the United States have a stroke-About 610,000 of these
are first or new strokes.
• About 185,00 strokes—nearly one of four—are in people who have had a previous stroke.
• About 87% of all strokes are ischemic strokes, when blood flow to the brain is blocked.
• Stroke costs the United States an estimated $36.5 billion each year. This total includes the cost of
health care services, medications to treat stroke, and missed days of work.
• Stroke is a leading cause of serious long-term disability.
11. Stroke- signs and symptoms
• "Brain Attack": is a new layperson term being used to describe a stroke. This term originated from
the need to emphasize to patients the urgency of a stroke and the need for immediate evaluation.
• Signs: sudden onset of weakness or numbness of one side of the body, sudden loss of vision, sudden
loss of speech, or sudden dizziness and unsteadiness.
• Cause: A brain attack occurs when one of the blood vessels to the brain becomes blocked. This
keeps blood from flowing to that part of the brain.
• Treatment - Thrombolytic (e.g., tPA, Altepase): There are thrombolytic medications (":clotbusters":)
that can be used to treat some patients with a brain attack. However, the thrombolytic must be
given within 3-4.5 hours of symptom onset. Because of this narrow window only about 2-3% of all
stroke patients qualify to receive this medication.
12. Stroke- risk factors
• Past hx of TIA
• HTN, High Cholesterol, DM, Heart Disease, Sickle Cell.
• Modifiable Risk Factors: Smoking, excessive ETOH use, lack of exercise, unhealthy diet, being
overweight.
• Unmodifiable Risk Factors:
• Age. The chance of having a stroke about doubles every 10 years after age 55.
• Sex. Men are more prone to having a stroke, but women are more likely to die from a stroke than
men. Pregnancy and use of birth control pills pose special stroke risks for women.
• Race or ethnicity. African Americans, Hispanics, American Indians are at higher risk
References:
- American HeartAssociation/American Stroke Association. Understanding Risk Web site.Accessed December 4, 2013.
- GoAS, Mozaffarian D, RogerVL, Benjamin EJ, Berry JD, BordenWB, et al. Heart disease and stroke statistics—2013 update: a report from theAmerican Heart
Association. Circulation. 2012:e2–241.
13. assignment
• Open a TEST TICKET and put the word “Stroke” into the Keyword Search. Note the 4 protocols that
come up.
• Click on the STROKE (Neurologic Deficit Adult) Protocol. Review Disease Definition, Background
information, all dispositions and home care advice.
• Once you have reviewed the above protocol, move on to the next slide/s and answer the questions.
After you have completed all assignments in this presentation, email your answers to :
marci.lawing@triagelogic.com
14. Stroke- pop quiz!
• 1. An ABCD2 score of 4 (four) puts your patient at: low, moderate or high risk of having a stroke?
• 2. tPA must be started within how many hours from the onset of symptoms to be effective in
treating a stroke?
• 3. Name 3 modifiable and 3 non modifiable risk factors of Strokes.
• 4. Your patient presents with [1] Weakness (i.e., paralysis, loss of muscle strength) of the face,
arm or leg on one side of the body AND [2] sudden onset AND [3] present now. What is your
disposition and method of transportation?
15. Diabetes statistics in the U.S. from cdc.gov
2014
• As of 2010, 25.8 million people—8.3% of the population—have diabetes
• In 2010, 10.9 million, or 26.9%, of people age 65 and older had diabetes.
• About 215,000 people younger than 20 years have diabetes (type 1 or
• type 2)
Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of
blindness among adults in the United States.
• Diabetes is a major cause of heart disease and stroke.
• Diabetes is the seventh leading cause of death in the United States
16. Diabetes- direct and indirect cost (cdc.gov)
• Estimated diabetes costs in the United States, 2007
• Total (direct and indirect): $174 billion
• Direct medical costs: $116 billion
• After adjusting for population age and sex differences, average medical expenditures of people dx
with diabetes were 2.3 times higher than those without diabetes.
• Indirect costs: $58 billion (disability, work loss, premature mortality)
17. Stages of hyperglycemia
• Mild hyperglycemia: Most often patient will have no symptoms.
• Moderate hyperglycemia: polyuria, polydipsia, fatigue, blurred vision.
• Severe hyperglycemia: confusion and coma.
• Diabetic ketoacidosis (DKA): fruity odor on breath, vomiting, rapid breathing, weakness, confusion,
and coma.
18. Diabetes-Tips for triaging a diabetic
Get a current BS reading (if possible)
Ask what medications they take, how much and when they take them. What type of insulin and how
much. If they are on a pump- what is their basal rate and bolus rate. If you need to page an MD,
he/she may want this information.
Illness, stress (good or bad stress), steroids, emotional issues are a few things that can affect BS
readings. Regardless of the reason for the elevated BS- Always triage what the patients symptoms
are.
Ask if the patient has a “Sick Day Rule Plan”.
Diabetes is EXPENSIVE- ask if they are taking their medications correctly. Encourage them to reach
out to their physicians or local resources if they are having trouble affording their medications.
Many insurance companies offer Diabetes Education- Encourage them to seek help this way if they
need help controlling their Diabetes
19. Assignment:
• Open a TEST TICKET and review the Diabetes- High Blood Sugar and Diabetes- Low Blood Sugar
Protocols including Background information, All disposition, Home Care advise for all categories and
the Sick Day Rules for patients on Insulin and those not on Insulin.
• Be familiar with types of medications (background information) and types of Insulin available.
• Once you have reviewed the above protocols, move on to the next slide/s and answer the
questions. After you have completed all assignments, email your answers to :
marci.lawing@triagelogic.com
20. Diabetes pop quiz!
• 1. Name 3 main causes of high blood sugar.
• 2. True or False: Type 2 Diabetics are NOT prone to DKA.
• 3. Name the 5 main types of insulin and when each one peaks
• 4. True or False: Insulin dependent diabetics should stop taking their insulin when they are ill?
• 5. Name 4 symptoms that would be a red flag to you that your patient could be in/going into DKA.
21. Myocardial infarction (MI)-statistics from
cdc.gov 2014
•Every year about 715,000 Americans have a heart attack. Of these, 525,000 are a first heart
attack and 190,000 happen in people who have already had a heart attack.
•About 15% of people who have a heart attack will die from it.
•Almost half of sudden cardiac deaths happen outside a hospital.
22. MI-Risk factors
Diabetes
Overweight and obesity
Poor diet
Physical inactivity
Excessive alcohol use
HTN
high blood cholesterol
Smoking
having had a previous heart attack or stroke
23. Heart disease in men-from cdc.gov
• Heart disease is the leading cause of death for men in the United States, killing 307,225 men
in 2009—that’s 1 in every 4 male deaths.
• Heart disease is the leading cause of death for men of most racial/ethnic groups in the United
States, including African Americans, American Indians or Alaska Natives, Hispanics, and whites.
For Asian American or Pacific Islander men, heart disease is second only to cancer.
• About 8.5% of all white men, 7.9% of black men, and 6.3% of Mexican American men have
coronary heart disease.
• Half of the men who die suddenly of coronary heart disease have no previous symptoms. Even
if you have no symptoms, you may still be at risk for heart disease.
• Between 70% and 89% of sudden cardiac events occur in men.
24. Heart disease in women-from cdc.gov
• Heart disease is the leading cause of death for African American and white women in the United
States
• Around the same number of women as men die each year of heart disease in the United States.
• About 5.8% of all white women, 7.6% of black women, and 5.6% of Mexican American women have
coronary heart disease.4
• Almost two-thirds (64%) of women who die suddenly of coronary heart disease have no previous
symptoms.
25. Symptoms of mi in women
• While some women have no symptoms, others experience angina (dull, heavy to sharp chest
pain or discomfort), pain in the neck/jaw/throat or pain in the upper abdomen or back. These
may occur during rest, begin during physical activity, or be triggered by mental stress.
• Women are more likely to describe chest pain that is sharp, burning and more frequently have
pain in the neck, jaw, throat, abdomen or back.
• Sometimes heart disease may be silent and not diagnosed until a woman experiences signs or
symptoms of a heart attack, heart failure, an arrhythmia, or stroke.
• http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm
26. assignment
• Open a TEST TICKET and type in the words “heart attack” in the Keyword search field. Review the
Chest Pain and Heart Attack Post Hospitalization follow up Protocols including Background
information, all dispositions and the home care advice for all categories
• Once you have reviewed the above protocols, move on to the next slide/s and answer the
questions. After you have completed all assignments, email your answers to :
marci.lawing@triagelogic.com
27. Heart attack- pop quiz!
• 1. What is the most common cause of acute coronary syndromes?
• 2. Name 3 symptoms a woman may have that would be a “red flag” to a triage nurse that she may
be having an MI?
• 3. What are 4 risk factors that place your patient at high risk for MI?
• 4. Besides chest pain what are 3 symptoms associated with cardiac ischemia?
• 5. True or False: BEFORE calling EMS the patient should be instructed to chew an aspirin (160 to
325 mg)?
28. PREGNANT women-choosing the right
protocol
• There are many pregnancy related protocols to keep in mind when triaging an expectant mother.
• It is important to be familiar with your choices BEFORE you get a pregnancy call.
• Most importantly- r/o the need to call EMS (examples: “Are you stable at this time?”, Are you having
severe pain or bleeding?”)
• Ask either EDC or “how many weeks pregnant are you as of today” to narrow down your guideline
choices.
• Start your keyword search with “Pregnancy” to bring up all of the Pregnancy protocols. If the
patients symptoms are not covered in a Pregnancy guideline, then you can look under a Non
Pregnant Protocol (example: pregnant with runny nose and mild cough- there is not pregnancy
protocol for these symptoms so the nurse should r/o any “pregnancy issues” and then use the Colds
Protocol but should NOT recommend any medication listed under that protocol unless it is on an
approved list provided to the mother by her obstetrician .
29. Take into consideration when triaging a
pregnant patient:
• Red Flags for Triage Nurse:
• No prenatal care
• Chronic or other medical illness
• Multi-parity
• History of prior rapid delivery
• Distance from the hospital
• Weather conditions.
30. Rules of thumb
• Once an ectopic always an ectopic until proven otherwise.
• When in doubt- send them out!
• Medications during pregnancy are generally not encouraged unless recommended by their
Obstetrician- Many will give their patients a list of “safe” medications to take- only encourage them
to take what is on that list.
31. True labor vs Braxton hicks (false labor)
TRUE LABOR
• Contractions become fairly regular.
• Contractions over a time period become stronger and
more frequent.
• Contractions continue to increase in intensity with
walking around.
• Contractions typically start in the lower back and
wrap around to the lower abdomen.
• Bloody show.
• Rupture of membranes occurs (may occur late in
labor).
• In real labor the contractions cause effacement and
dilatation of the cervix.
BRAXTON HICKS
• Contractions are irregular.
• Contractions do not increase over time in
frequency or strength.
• Contractions decrease with activity, for
example, walking.
• The pain from contractions tends to be
experxienced in the upper abdomen rather
than in the back or lower abdomen.
• In false labor contractions do not cause
effacement or dilatation of the cervix.
32. Assignment
• Open a TEST TICKET and type in the words “pregnancy” in the Keyword search field. Review the
Pregnancy Protocols including Background information, all dispositions and the home care advice for
all categories
• Once you have reviewed the above protocols, move on to the next slide/s and answer the
questions. After you have completed all assignments, email your answers to :
marci.lawing@triagelogic.com
33. Pregnancy- pop quiz!
• 1. Your patient is 37 weeks pregnant with new onset of leg swelling and moderate headache.
Which protocol are you going to use?
• 2. Your patient is 22 weeks pregnant with new onset of vaginal bleeding, “like a period”. What
protocol are you going to use?
• 3. Your patient is 6 weeks pregnant with new onset of lower abdominal cramping, vaginal spotting.
Hx of ectopic pregnancy in past. What protocol are you going to use?
• 4. Your patient is 20 weeks pregnant with a runny nose, cough and fever x 1 day. What protocol
are you going to use and what is your advice regarding taking OTC medications?
34. Additional Tips for triaging adults
• Always read your Disease Definition before choosing guideline
• Be familiar with the background information for major health threats (Diabetes, Heart
Disease, Stroke, Pregnancy)
• Always ask for current medications including OTC vitamins and supplements: This can
clue you in on any health concerns the patient did not tell you about.
• Many adults have co-morbidities (more than 2 health condition) which increases the
likelihood of complications.
• Follow the protocols w/o skipping those “uncomfortable questions” re: drug/alcohol use
or abuse.
• Triage with a sense of urgency for Chest pain, Neuro symptoms- “Time is Tissue”- The
sooner an MI or CVA gets to the ED, the sooner life/tissue saving medications can be
started (i.e. Thrombolytic (e.g., tPA, Altepase) must be started within 3-4.5 hrs of onset
of symptoms to be effective)
35. Sources
Nursing Care of Older Adults
http://www.nursingcenter.com/lnc/static?pageid=730388#sthash.yfbRIqXA.dpuf 8/28/2014
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/hds_index.htm 8/24/2014
Know the Signs and Symptoms of a Heart Attack
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heartattack.htm 8/24/2014
