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Care of the Traumatized Older Adult

Nurses need knowledge and skill to care for older adult patients with trauma.
BY LESLIE MYRICK ROBBINS/ NANCY FLEMING COURTS

Older adults are experiencing excellent health and maintaining active lifestyles. They continue to engage in the activities they have enjoyed throughout their lives, but as they grow older they are at increased risk for injury related to these activities. Older adults suffer injuries of equivalent severity as those of younger patients; however, the consequences are much more severe. The older adult presents a unique and complex scenario that requires nurses to understand the normal physiological changes of aging and the effects of chronic disease. This article provides guidelines for the emergency care of the older adult patient with trauma and emphasizes areas that require special considerations. Geriatr Nurs 1997; 18:209-15.

trauma in the older adult is a growing conT reating cern. Trauma is the seventh leading cause of death in people over age 65 and is an increasingly significant health problem in older adults.l As older adults experience good health and maintain an active life style, they continue to engage in activities they have enjoyed throughout their lives, but they are at greater risk for injury related to these activities. Available research indicates that older patients with trauma have an increased mortality rate from trauma in spite of relatively low injury severity scores. 2-6 Older adults have higher mortality rates and longer hospital stays 2,7 than younger patients with similar injuries. Response to injury is dependent on the extent of individual physiological characteristics and existing conditions. Preexisting medical conditions such as ischemic heart disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, cirrhosis, coagulopathy, and diabetes complicate the treatment response and recovery and increase the risk of death in older patients with trauma. 8'9 The injured older adult presents a special challenge to the nurse, necessitating efficient and

LESLIE MYRICK ROBBINS, MSN, RN, is the trauma nurse coordinator at Forsyth Memorial Hospital in Winston-Salem, N.C., and NANCY FLEMING COURTS, PhD, RN, NCC, is an associate professor at the School of Nursing, the University of North Carolina at Greensboro. Copyright 1997 by Mosby-Year Book, Inc. 0197-4572/97/$5.00 + 0 34/1/83465

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aggressive care. This article alerts the nurse to the special considerations when caring for a traumatized older adult.

Types of Injury
Falls. Falls are the most frequent Cause of injury in the older population. As a result of falls, approximately 7 million injuries occur per year. 1 Falls occur as a result of age-related alterations in balance, motor strength, and coordination. Older adults are more prone to tripping and are less able to counteract a fall as a result of slower reaction times. Many of those who fall sustain a single orthopedic injury, such as a fractured humerus, ankle, or wrist. 8 One quarter of the older people who fall have more significant injuries. These injuries may include a pelvic fracture, hip fracture, multiple fractures, rib fractures with pulmonary injury, or head injury. 1 Acute or preexisting illnesses such as arthritis, cerebrovascular accidents, arrhythmias, and diabetes frequently contribute to falls. Syncope, a Common cause of falls, is produced by a lack of oxygen to the brain from a decrease in cerebral blood flow or metabolic change. A decrease in oxygen supply to the brain leads to changes in mental acuity, sensory interpretation, motor response, and a reduced capacity to cope with multiple stimuli, l Older adults may also experience sudden weakness in their extremities, leading to falls. 8 An estimated 50% of older adults with significant injuries from falls die within 1 year. The death frequently is not a result of the fall itself but is secondary to preexisting disease, consequences of extended immobility, or resulting lifestyle changes. 1 M o t o r vehicle injuries. The risk of a motor vehicle crash rises with age. The 75 and older age group has the highest rate of fatal crashes and a crash rate second only to that of drivers aged 16 through 25 years. 11 Unlike younger drivers, older adults often become involved i n crashes within a few miles of home, in good weather, and during day light hourS. 8 These may be precipitated by a decrease in sensory perceptions, a slower reaction time to environmental stressors, and preexisting medical condi210 Robbinsand Courts

tions, such as coronary artery disease, cerebrovascular diseases, and arthritis. 1,1e A pedestrian struck by a vehicle is one of the most devastating mechanisms of injury to an older adult. People age 65 years and older have the highest pedestrian death rates. For example, 46% of all deaths that occur at crosswalks occur in those 65 years and older. Twenty five percent of all older adult pedestrian deaths occur at intersections. 13 Most signals at intersections are programmed to allow a pedestrian to cross at a rate of 4 feet per second. Many older adults are unable to cross the intersection in this amount of time. The inability of an older person to move out of the path of a vehicle and to look in all directions to see oncoming traffic contribute to the frequency of injury. 8 Burns. Burn injuries in the older adult are associated with a high mortality rate. Approximately 50% of older adults who experience burns to 30% or more of their body will not survive. Burns create high physiological demands, and older adults with diminished physiological reserve have difficulty compensating and recovering from burns. 1 Crime. Falls, vehicular trauma, and burns account for most serious injuries in older adults; however, older adults are also frequently victims of violent crime. Although assaults with blunt objects are the most commonly reported crimes that involve older adults, urban trauma centers are documenting an increased incidence of older adults with penetrating injuries. 8 The mortality rate of these victims is four times higher than that of younger victims because of the relatively limited physiological reserves. 1 Abuse. Abuse of older adults is also a concern. Traumatic abuse of elders includes physical violence and neglect. 14 Frequently abuse is evidenced by unusual and unexplained injury patterns such as burns in strange locations, unexplained fractures, and bruises and fractures in various stages of healing. 15 Other symptoms of abuse or neglect include unexplained malnutrition and dehydration, sexually transmitted disease, health care hopping, missed appointments, poor personal hygiene, depression, withdrawal, and misuse of medications. 14

Emergency Care
As with all patients with trauma, airway, stability of the cervical spine, breathing, and circulation are the first concerns, followed by a neurologic assessment and history. If any life-threatening injuries are identified, interventions to correct these injuries should be implemented immediately. After the patient's condition has been stabilized, a full head-to-toe assessment is necessary to identify all injuries and provide a baseline for changes. The critical considerations for traumatized older adults are summarized in BOx 1. Clear and assess the airway for patency. Open the airway by use of the chin lift or jaw thrust method, be careful to maintain cervical spine immobilization. Inspect the upper airway for the presence of foreign objects, loose teeth, blood, vomitus, or the tongue blocking the airway.
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Remember that many older adults have dentures that can fall out of place and obstruct the airway. 15 Remove foreign debris and suction the mouth if necessary. Simultaneously stabilize the cervical spine as the airway is inspected. The older adult has an increased risk for spinal cord injury from the narrowing of the cervical canal and osteoarthritis. 12 Patients with potential neck or spinal cord injuries are immobilized on a long backboard with a cervical hard collar and cervical blocks until fractures have been ruled out by radiologic examination.

Supplemental oxygen is recommended but may be detrimental to patients with chronic obstructive pulmonary disease who are dependent on underlying hypoxia to maintain their respiratory drive.
Normal degenerative changes of aging make cervical spine clearance (radiographic visualization of C1 through C7) more difficult. In some cases additional radiography, computed tomography, or magnetic resonance imaging is needed to clearly view the cervical spine. In addition posrural changes of aging such as kyphosis make cervical spine immobilization difficult and uncomfortable for patients. Padding under the head prevents excessive hyperextension of the neck, which can lead to difficulties with airway management. Obvious bony deformities should be padded and carefully positioned to maintain proper alignment and comfort. 15 It is important to minimize pain and prevent further injury. Older patients are removed from backboards as soon as possible to prevent pain, respiratory compromise, and skin breakdown. Careful monitoring of respiratory status is essential. Assessment and reassessment of breath sounds, chest excursion, and respiratory effort must be performed as frequently as the patient's condition warrants. Normal aging reduces vital capacity and functional residual capacity, decreases elasticity, and limits the expansion of the chest wall, thus reducing the ability to cough. These changes contribute to pulmonary compromise. 1 Early identification of hypoxia through blood gas analysis and pulse oximetry followed by prompt intervention may prevent complications caused by hypoperfusion. 12 In the older adult, the normal oxygen saturation is decreased to about 93% to 94% and the Pao 2 (arterial oxygen tension) to 75 to 80 mm Hg. 16 Supplemental oxygen is recommended but may be detrimental to patients with chronic obstructive pulmonary disease who are dependent on underlying hypoxia to maintain their respiratory drive. Early intubation and mechanical ventilation must be considered for a respiratory rate greater than 40 and a Paco 2 more than 50 torr. Intubation does produce an increased risk of pulmonary complications, but airway obstruction, hypoxia, and increased effort to breathe can lead to death. 17 Special care should be taken to assist the elder in obtaining an optimal position to assist with breathing. If the patient's condition allows, the head of the bed should be elevated to assist with respirations and clearance of secretions. A quick circulatory assessment begins with palpation of the femoral or carotid artery pulse for quality. A readily palpable femoral or carotid artery pulse approximates a systolic blood pressure of 60 to 70 mm Hg. 14 The skin is inspected for color and palpated for temperature and degree of diaphoresis. Any uncontrolled external bleeding must be stopped immediately with direct pressure. Patients with signs of inadequate circulation, such as tachycardia, decreased level of consciousness, uncontrolled bleeding, pale, cool, diaphoretic skin, and distant heart sounds must have fluid resuscitation initiated immediately. The older adult may seem to be hemodynamically stable while experiencing inadequate perfusion. The young heart responds to increased demand for oxygenated blood by increasing heart rate in response to an increased level of circulating catecholamines. Although the production of catecholamines continues, sensitivity to the cate211

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A thorough history of the injury is obtained from the cholamines decreases in older adults. 16 For this reason, the expected compensatory tachycardia produced by patient, family, and prehospital personnel. Information shock may not occur, and a diminished heart rate may obtained from prehospital personnel includes mechanism even be observed, s Also, the ability of the heart to re- of injury, injuries sustained, vital signs, and treatment bespond to injury may be further compromised by beta fore arrival. If the patient is responsive, it is important to blockers and diuretics taken by many older patients. 15 assess for significant events that may have caused the injury. For example, a patient may experience chest tightTable 1 summarizes the emergency care. ness and shortness of breath before losing control of their car and hitting an embankment. 15 Special Considerations A reliable history provides valuable information about the patient's baseline status and can completely alter the The condition of a seemingly stable older patient can treatment plan. To illustrate, a deteriorate rapidly and with patient with a history of corofew warning signs. An 80nary artery bypass grafting has year-old patient has half the an increased risk for cardiac cardiac output as a 20-yearand thoracic aorta injury. A old patient) The cardiac outthorough medical history can put may be sufficient during prevent a "false sense of secunormal activity, but the heart rity" in patients with no apparof the older adult may have ent life-threatening trauma. 8 difficulty responding to inThe medical history includes jury. Older adults are intolermedical illnesses, previous ant of hypoperfusion and its surgeries, advance directives, consequences. Untreated current medications, allergies, hypoperfusion can lead to cardiogenic shock, multisystem organ failure, and death. immunization status, and the time of the patient's last Early hemodynamic monitoring including measurement meal. A search for medical alert cards, bracelets, and lists of oxygen delivery and oxygen consumption is essen- of medications kept in the wallet may be fruitful. The patial. 18 Arterial pressure monitors, central venous pressure tient's family physician should be contacted as soon as lines, and pulmonary artery catheters provide an accurate possible and can provide valuable insight into the prior assessment of the cardiopulmonary system and guide health of the patient. Additional information regarding fluid replacement. 14 Delays in recognition and treatment the patient's degree of independence and daily activities increases appropriate nursing goals and guides long-term of underperfusion result in death. 18 A decrease in sensory perceptions may imitate signs of decisions. 14 The amount of fluid given to the older patient is simian altered level of consciousness related to injury. lar to that of the younger patient and is monitored careBaseline patient neurologic status, obtained from the family, provide assessment parameters. Neurologic as- fully. During initial fluid resuscitation, isotonic sessments with the Glasgow Coma Scale (GCS) identify electrolyte solutions are used for all patients with trauma. changes and trends in the neurologic status. ~7 The GCS is Isotonic fluids promote transient intravascular expansion an internationally recognized assessment scale of head and maintains the vascular volume by replacing accominjury severity and degree of coma. The overall score panying interstitial fluid losses. Fluid resuscitation of a ranges from 3 to 15 and is the sum of the best response patient with inadequate circulation is initiated by giving from three subscales: eye opening, motor response, and 1 or 2 L as rapidly as possible. The use of large-bore, verbal response. In general, the lower the GCS score, the short catheters, short intravenous tubing, and a rapid inmore severe the coma and the greater the risk of morbid- fuser device will contribute to rapid infusion. It is important to assess the patient's response to the fluid bolus by ity and death. 14 Any older adult admitted with increased drowsiness, measuring the blood pressure, heart rate, level of conconfusion, and cognitive impairment with a history of a sciousness, and breath sounds. The amount and rate of fall several days prior must be assessed for neurologic in- fluid administration are unique for each individual. jury. Confusion and depressed cognitive ability alert the Further fluid resuscitation is guided by the patient's renurse to the possibility of subdural hematoma. Patients sponse. Some patients will respond rapidly to the initial with acute subdural hematomas usually manifest symp- fluid bolus, and their condition will remain stable. toms within 48 hours of the injury event. As the brain Assessment for clinical signs of shock and hemodynamic ages, the dura adheres tightly to the skull, and the brain parameters of these patients is essential, and blood must decreases in Size. The space between the brain and the be immediately accessible. 17 Some patients will initially respond to the fluid with surface of the skull increases, and the bridging veins are stretched. A minor blow to the head can cause significant an improved blood pressure and slower pulse, but as the bleeding into this space. Subdural hematomas occur three rate of fluid administration is decreased, signs of hypotimes more frequently in the older adult who can have volemia return. Continued fluid and blood administration large subdural hematomas with minimal clinical symp- are required in these patients, as is determination of the toms. 17 cause of hypotension. A third type of patient will respond

Closely monitor the patient's temperature because

hypothermia increases the risk of complications.

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minimally to fluid resuscitation. Frequently, this type of patient will require immediate transfusion with type specific blood and emergency surgical intervention resulting from ongoing blood loss. Massive transfusions sometimes required for these patients are associated with several complications, including hypothermia, electrolyte disturbances, and coagulopathy, but this risk must be taken when treating a patient in shock who does not respond to fluid resuscitation. The use of blood and fluid warmers and frequent serum electrolyte studies will help decrease the risk of these complications] 7 Perfusion and renal function are monitored by the insertion of an indwelling urinary catheter. The inability of the kidneys to concentrate urine may precipitate inappropriately high urinary output during hypovolemia; therefore urinary output is a poor measure of perfusion. 14 Insertion of a catheter does increase the risk of infection in elderly patients, but it is justified for its monitoring value. Closely monitor the patient's temperature because hypothermia increases the risk of complications. The norm for each patient needs to be established and assessed for trends. Once the norm is established, an increase in temperature alerts the nurse to the possibility of infection. The older adult has an altered ability to regulate body heat production and heat loss related to decreased metabolic rate, hypothyroidism, peripheral vascular changes, and decreased muscle mass. The older adult with less muscle mass is unable to produce an adequate amount of heat and is unable to conserve heat in spite of increased body fat. Keep the patient's skin covered whenever possible to reduce heat loss. Passive rewarming such as heat lamps, warmed intravenous fluids, warm blankets, and heated humidification, are necessary for patients. 14 Older adults cannot be relied on to complain of cold because they may not feel it, even if they have hypothermia. Older adults are at risk for over- and undertreatment of pain. They often report pain very differently from younger patients as a result of physiological, psychological, cohort, and cultural differences associated with aging. Some older adults are very stoic regarding pain. Pain thresholds vary. Some elderly patients do have a decreased response to noxious stimuli, but pain must be assessed by the individual. If the patient is awake and alert, it is not only important to assess the pain itself but the patient's beliefs about pain. If the patient is unconscious or confused, the pain assessment is based on indicators such as facial grimacing, withdrawal, body posturing, and autonomic signs such as pupillary dilation, diaphoresis, and respiratory changes. Effective pain control takes into consideration the age of the patient and preexisting illnesses and achieves maximum comfort while maintaining function. 12 The type of pain the patient is experiencing influences the type of pain management. Narcotics are used to relieve acute pain from trauma. The renal changes resulting from aging slow the excretion of drugs. Drug doses therefore can not be calculated on the basis of the serum creatinine. 15 The narcotic dose is reduced to 25% to 50%

that of younger patients. Side effects of narcotics may include respiratory depression, hypotension, nausea, vomiting, and constipation effects. 16 Older adults, more sensitive to opioids than other age groups, respond to a dose of an opioid such as morphine as if it were four times greater. Opioids, however, may be used because the effect lasts longer, it requires less frequent doses, and side effects can be easily reversed. Opioids must be carefully titrated to the desired effect. The individualization of drug dosing is critical in the older adult population. 14 Communication is achieved through vision, touch, and hearing. It should not be assumed that all older adults have deterioration in vision, speech, hearing, and touch. Determine whether the patient has a sensory deficit and uses a hearing aid or eye glasses. Have the family bring them as soon as possible and be sure they are in working order. It is important to seek eye contact and speak slowly and clearly. Shock and anxiety impair concentration. Explain what has happened to the patient and repeat often. Questions should be phrased very simply and repeated when necessary. If the patient has a hearing deficit, speaking into the better ear can be beneficial. Speech should be clearly enunciated and in an audible tone. Beware of shouting at patients. Verbal communication reinforced with touch is reassuring to the patient. Touch implies caring, comfort, and worth. Visual communication consists of written material, facial expressions, or physical environment. It is important to have a consistent person available. Bright light can help with visual acuity when needed. 14 Injury occurs without warning and changes the lives of patients and their families. The coping skills used on a daily basis are not useful for the intense emotional, physical, social, and spiritual needs caused by a traumatic injury. The nurse needs to learn about coping skills that have been used in past emergencies. A member of the family or a friend who can provide support should be identified and remain with the patient. The nurse should actively listen to the patient's thoughts, concerns, and needs and encourage the patient to express feelings that may relieve tension. ~5 The best outcomes noted for hospitalized older adults occur in those patients who are relatively independent at the time of injury and who do not live alone. An older adult who feels needed and wanted has an increased chance of a good outcome. On the other hand, social isolation, loneliness, residence in a nursing home, and infirmity seem to contribute to increased levels of postinjury dependence. 14 The older adult patient with trauma presents a unique challenge to the nurse. Nurses need knowledge and skill to care for this diverse group. The normal physiologic aging processes vary from person to person and increase the need for individualized treatment, efficient nursing assessments, and carefully planned interventions. There is very little room for error. The nurse must be aware of the factors that affect the care of the older adult patient with trauma. Outcomes are greatly dependent on good nursing care.

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REFERENCES 1 . Scalea TM. Trauma in the elderly. Emerg Med 1995;27:44-62. 2. Shabot MM, Johnson, CL. Outcome from critical care in the "oldest old" trauma patients. J Trauma 1995;39:254-60. 3. Bobb JK. Trauma in the elderly. J Gerontol Nurs 1987;13:28-31, 4. Carrillo EH, Richardson JD, Malias MA, Cryer HM, Miller FB. Long term outcome of blunt trauma eare in the elderly. J Trauma 1993;176:559-64. 5. Knudson MM, Lieberman J, Morris JA, Cushing BM, Stubbs HA. Mortality factors in geriatric blunt trauma patients. Arch Surg 1994;129:448-53. 6. Sluis CK, Klasen HJ, Eisma WH, Duis HJ. Major trauma in the young and old: what is the difference? J Trauma 1996;40:78-89. 7. Champion HR, Copes WS, Buyer D, Flanagan M, Bain L, Sacco W. Major trauma in geriatric patients. Am J Public Health 1989;79:1278-82. 8. Schwab CW, Kauder DR. Trauma in the geriatric patient. Arch Surg 1992;127:701-6. 9. Morris JA, MacKenzie EJ, Edelstein SL. Effect of preexisting conditions on the mortality in trauma patients. J Am Med Assoc 1990;263:1942-6.

10. Bullock BL, Rosendahl PP, editors. Pathophysiology: adaptations and alterations in function. Philadelphia: Lippincott, 1992. 11. National Safety Council. Accident facts: 1991 edition. Chicago: National Safety Council; 1991. 12. Keough V, Letizia M, Baldonado A. Facing the challenge of elderly trauma. J Gerontol Nuts 1994;20:5-11. 13. Insurance Institute for Highway Safety. Pedestrians. Arlington: Insurance Institutes for Highway Safety. 14. Cardona VD, Hum PJ, Basenagel Mason PJ, Scanlon AM, Veise-Berry SW, editors. Trauma nursing: from resuscitation through rehabilitation.Philadelphia: Saunders, 1994. 15. Neff JA, Kidd PS, editors. Trauma nursing: the art and science. St. Louis: Mosby-Year Book; 1993. I6. Stanley M, Beare PG, editors. Gerontological nursing. Philadelphia: FA Davis, 1995. 17. Demarest GB, Osler TM, Clevenger FW. Injuries in the elderly: evaluation and initial response. Geriatrics 1990;45:36-42. 18. Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJA, Phillips TF, et al, Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990;30:129-36.

1. What is the most frequent, cause of injury to the older population? A. Motor vehicle accidents B. Falls C. Crime D. Abuse 2. What is the mortality for older adults who experience a significant fall within one years time? A. 10% B. 25% C. 50% D. 75% 3. What is the percentage of older adults (over the age of 65 years) who die from pedestrian injuries? A. 12% B. 46% C. 75% D. 82% 4. Older adults may have more problems with airway management because: A. Their jaws are more fragile B. They may have dentures that can fall out of place C. They are more frequently injured to the jaw and head areas 5. What is the normal oxygen saturation in the older adult? A. 93% to 94% B. 95% to 96% C. 97% to 98% D. 98% to 99% 6. When should intubation and mechanical ventilation be considered in the older adult? 214
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A. Respiratory rate is more than 40/minute, and Paco 2 is more than 50 torr B. Respiratory rate is 30 to 40/minute and Paco 2 is more than 35 torr C. Respiratory rate is more than 25/minute and Paco 2 is less than 50 torr D. Respiratory rate is 35 to 45/minute and Paco 2 is 40 torr 7. The palpable femoral or carotid pulse is equal to a systolic blood pressure of: A. 60-70 mm Hg B. 70-80 mm Hg C. 80-90 mm Hg D. 90ram Hg 8. If you are concerned your elder patient may be in shock, but you do not see a compensatory tachycardia, you should: A. Not worry, they are not in shock B. Wait until they become tachycardic C. Check to see if they are on beta blockers or diuretics 9. Older patients with acute subdural hematomas become symptomatic within: A. 12 hours B. 24 hours C. 36 hours D. 48 hours 10.An increased level of post injury dependence is augmented by all of the following EXCEPT: A. Social isolation B. Residence in a nursing home C. Not living alone and having good family support

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11. Which age group has the highest rate of fatal motor vehicle crashes? A. 60 to 65 years B. 66 to 70 years C. 71 to 74 years D. 75 years and older 12. What intervention should be performed simultaneously as the airway is assessed? A. Initiate two intravenous lines B. Obtain a past medical history C. Stabilize the cervical spine D. Administer oxygen by cannula or mask 13. The older adult trauma patient has an increased risk for spinal cord injury as a result of: A. Increased elasticity of the joints and ligaments B. Postural changes C. Increased bone density D. Narrowing of the cervical canal 14. Early intubation and mechanical ventilation: A. Increases complications and should only be used as a last resort B. Should be considered for all older trauma patients with respiratory distress C. Should be avoided in all older trauma patients D. Are usually futile in older adult trauma patients 15. Older adult trauma patients tolerate hypoxia: A. Well, unless there is underlying pulmonary disease B. Very poorly C. Fairly well if they are relatively healthy D. Fairly well, if care is taken to avoid exertion 16. Which symptoms of shock may not be present in the older adult? A. Tachycardia B. Hypotension C. Cool, clammy skin D. Delayed capillary refill

17. A 77-year-old woman arrives in the emergency department with confusion and depressed cognitive ability. Her family states that she fell out of bed 5 days ago but was not injured. The nurse suspects the patient is exhibiting signs of: A. Cerebrovascular accident B. Hypoxia C. Subdural hematoma D. Hypoglycemia 18. When immobilizing the injured older adult, the nurse should: A. Place padding under the patient's head to prevent excessive hyperextension of the neck B. Not apply a hard cervical collar because it may compromise the airway C. Keep the patient's neck in flexion to prevent airway obstruction D. Not use a backboard because it may cause pressure on the lower back 19. An 80-year-old man arrives in the emergency department after a motor vehicle crash. His blood pressure is 998/52 m m Hg, pulse rate of 96 beats/rain, and respiratory rate of 30 breaths/min. The initial fluid resuscitation should be: A. Isotonic solution at 150 ml/hr and assess every 4 hours B. 1000 ml isotonic solution as quickly as possible then assess the patient's response C. Rapid blood administration D. 250 ml isotonic solution as a bolus, then 4 units of whole blood over the next 4 hours 20. Pain medication should be administered to older adult trauma patients: A. Only if the patient asks for medication B. Only if the patient is conscious C. When the patient is stable D. If the patient is experiencing pain or discomfort

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