GERIATRIC UPDATE
GERIATRIC EMERGENCY NURSING: CASE STUDY
Authors: Joan Somes, RNC, PhD, CEN, CPEN, FAEN, and Nancy Stephens Donatelli, RN, MS, CEN, NE-BC,
Apple Valley, MN, and New Wilmington, PA
Section Editors: Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and Joan Somes, RNC, PhD, CEN, CPEN, FAEN
JEN will regularly feature this new column by Nancy Stephens
Donatelli, RN, MS, CEN, NEA-BC, and Joanie Somes, RNC,
PhD, CEN, CPEN, FAEN. An ENA member survey identified
the top list of geriatric nursing education needs as: differences
in pathophysiology associated with differences in the geriatric
patient, pharmacology and medication administration, falls,
geriatric safety, and sensory changes. This series addresses read-
er interest in and questions regarding the care of the older adult.
The editors request feedback and ideas from JEN readers re-
garding learning needs related to caring for the geriatric patient
in the emergency department. Please E-mail your specific ques-
tions or suggestions to question4gene@gmail.com. The editors
will collect reader responses and answer as many as possible via
E-mail or in JEN.
92-year-old woman was brought to the emergency
A department by EMS after she was found lying next
to an elevator door in a parking garage, where win-
ter temperatures were hovering at 5°F. The first impression
was a slightly confused, irritated older woman with a large
bloody dressing on the side of her head. Her airway
appeared to be intact. She complained of chest pain and
shortness of breath. Her color was fair, and she had distal
but irregular pulses (72 to 110 beats/min). Initially, she
was hypertensive at 180/90 mm Hg. Oxygen saturation
was intermittently “good” at 96% and then would fall as
low as 88%. The patient’s respiratory rate was 28
breaths/min. Her temperature was 97.7°F. Her skin felt
cold to the touch, and her fingers were dusky. She was
not exactly sure why she fell. She repeatedly stated that
Joan Somes, Greater Twin Cities Chapter ENA, is Staff Nurse/Department
Educator, St. Joseph’s Hospital, St. Paul, MN.
Nancy Stephens Donatelli, CODE Chapter ENA, is an Assessment Nurse,
Shenango Presbyterian SeniorCare, New Wilmington, PA.
For correspondence, write: Nancy Stephens Donatelli, RN, MS, CEN,
NE-BC, 155 Leesburg Station Rd, New Wilmington, PA 16142; E-mail:
question4gene@gmail.com.
J Emerg Nurs 2010;36:260-2.
0099-1767/$36.00
Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2010.02.012
260 JOURNAL OF EMERGENCY NURSING
she remembered reaching to “push the button” and then
hitting her head but did not believe she lost consciousness.
Frequently during the admission interview, she did not
respond appropriately to questions.
The geriatric patient has many physiologic changes
that need to be considered during assessment and treat-
ment. In fact, not considering these changes makes it very
easy to miss pertinent findings and potential problems.
Our first question was “Why did the patient find her-
self on the ground and not remember what happened?” She
insisted that she did not pass out, but it certainly sounded
like she did. The older adult with an acute myocardial
infarction may present with only a decreased level of con-
sciousness, weakness, or sudden shortness of breath. A 12-
lead electrocardiogram, as well as monitoring for dysrhyth-
mias (another reason for falls), is needed. The patient’s 12-
lead electrocardiogram and monitoring showed atrial fibril-
lation alternating with episodes of a pacemaker rhythm.
There was no ST-segment elevation, but not all acute myo-
cardial infarctions present with this “classic” sign. Labora-
tory studies looking for cardiac markers to rule out the
“silent myocardial infarction” would be needed.
Enough force to cause a head laceration can also lead
to cervical spine injury. Careful assessment for neck pain,
bony step-offs, and distal color, motion, and sensation is
even more important in older adults, because their bones
are less dense and more easily fractured. The older adult
patient has less muscle mass to spasm, thus losing an
effective mechanism that seems to prevent excessive
movement of the head and neck in younger patients. Col-
or, motion, and sensation changes may also be “normal”
for the geriatric patient with peripheral neuropathy,
stroke, and vascular disease. Spinal precautions needed
to be implemented. But, backboards and cervical collars,
as well as rigid splints, have been identified as causes of
skin breakdown and pressure sores in the older adult. Fre-
quent reassessment of pressure points with early as possi-
ble removal of these devices have to be added to plan of
care. Radiographs of our patient’s spine were not of much
help because of bone decalcification. She required a com-
puted tomography scan of her neck to look for fractures.
Even though our patient complained of rib pain, there
was no obvious sign of trauma to her ribs. Older adults have
bones that break just with the wrong movement. Our
VOLUME 36 • ISSUE 3 May 2010

patient was the typical frail lady who looked like the wrong
movement could lead to enough pressure on a bone that it
would break. Fortunately, there was no crepitus. Breath
sounds were equal but were diminished on the right—the
impact side. She had no abdominal, pelvis, or back pain.
However, she did have bruising and an abrasion of the left
knee. Application of ice to the knee to prevent swelling had
to be carefully done, to prevent frostbite to the area, because
the patient’s skin was very thin and in many places had old
bruising. Concern related to frostbite and skin breakdown in
the geriatric patient is because of loss of subcutaneous fat.
Pressure ulcers develop rapidly when bony prominences cov-
ered only by thin skin are pressed against hard surfaces, such
as the backboards, cervical collars, and splints noted pre-
viously, or when the patient is lying on the floor at home
for any length of time. Immobilization for as little as 30 to
45 minutes can start the breakdown process. Equipment
rubbing against thinned skin folds, such as oxygen tubing
over the ears, also leads to skin breakdown. Thus it is impor-
tant to evaluate bony prominences and “folds” looking for
”wear” due to pressure. (I have seen geriatric patients with
open areas on each of the spinous processes when they have
lain on the floor for several hours.)
It was determined that much of the patient’s confusion
was related to the reason she was in the parking garage. She
had an appointment at her hearing aid store, which is
located next to the garage. In the emergency department
she simply could not hear what was being said to her. Old-
er patients also have a difficult time distinguishing multiple
stimuli. When several staff members were “doing and ask-
ing” at the same time, she was put into sensory overload.
Once it was only the primary nurse speaking louder,
slower, and directly at her was she able to hear the ques-
tions and answer appropriately. This approach helped the
“apparent” confusion; however, she continued to ask the
same questions over and over.
Undressing the patient was a challenge because she was
still cold and wanted to keep her clothing on. Older
patients do not have the well-distributed body fat of youth
and want to hold on to their clothing in an effort to stay
warm. They also tend to be more modest than their young-
er counterparts.
The large bloody dressing covered a 4-inch laceration
that ran vertically in front of the patient’s ear from the tem-
ple past the ear lobe. Although it was too early to see Battle
sign and raccoon eyes, her complaint of a “runny nose”
prompted a check for cerebral spinal fluid leak, which
could signal a basilar skull fracture. Brain atrophy starts
at age 50 years; therefore the patient was at risk for vessel
shearing injury due to the movement of the brain inside the
skull. It would take longer for her to exhibit symptoms of a
May 2010 VOLUME 36 • ISSUE 3
Somes and Donatelli/GERIATRIC UPDATE
head injury because she would have more room for blood
to collect before symptoms appear. Checking the pupils
was of little help because the patient normally has unequal
pupils because of previous cataract surgery.
The patient’s list of medications included Coumadin,
a β-blocker, eye drops, and a diabetic medication.
Although all medications in the older adult can be proble-
matic, of primary concern in this patient was her Couma-
din. Her head injury put her at higher risk for intracranial
hemorrhage. Laboratory studies need to include an inter-
national normalized ratio, partial thromboplastin time,
electrolyte levels, hemogram, and a “just-in-case” tube
for a type and screen. The older adult often has a low
hemoglobin level. If the patient was going to need blood,
it would be good to have the type and screen tube in the
laboratory. Her β-blocker was going to affect how she
responded to blood loss by preventing the tachycardia
and vasoconstriction associated with shock. Confusion
can also be related to low blood sugar. The patient was
on a diabetic medication, so we were prompted to check
a finger stick blood sugar (which was normal) and a blood
glucose level.
Amazingly, all the patient’s radiographs and computed
tomography scans were negative. Her laceration took 11
sutures to close. She absolutely refused a tetanus booster.
Actually, she would have required the entire series includ-
ing HyperTET. Many older adults are in this same situa-
tion, because they have never had tetanus shots or it has
been so long since they had one that they need the entire
series repeated.
The patient had convinced the physician that she had
tripped and fallen. It was after the physician and primary
nurse had a chance to compare notes that the physician
asked to have the patient’s pacemaker interrogated.
The pacemaker interrogation showed that the patient
had gone into a very rapid atrial fibrillation with ventricular
response, lasting long enough that she could have become
slightly syncopal. The physician felt this best explained why
the patient was unclear as to why she fell over.
The patient’s blood pressure dropped to 112/80 mm
Hg in the emergency department, but the heart rate stayed
the same. Was this good or bad? Was she returning to her
baseline, or was she becoming hypotensive and unable to
compensate because of her “older” cardiovascular system?
The older adult’s blood vessels do not vasoconstrict as effi-
ciently because of atherosclerosis. Thus the drop in blood
pressure could be due to her being less anxious or due to
internal bleeding. A younger person can increase his or
her heart rate, but our patient was taking a β-blocker pre-
venting this. In addition, the older adult’s heart does not
typically does not typically increase rate by developing a
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GERIATRIC UPDATE/Somes and Donatelli

sinus tachycardia but goes into atrial fibrillation, which is
sometimes rapid. Initially, our patient had been very
anxious. She became less so and more alert with time, so
we believed that was she was returning to her baseline,
not decompensating.
Ultimately, the patient was admitted because of her
dysrhythmia. She lived at home alone. Her only family
was a niece who arrived about 2 hours after her admission.
The patient was still at risk of a concussion, pulmonary
contusion, or pneumonia because of her rib injury. She
would be off balance because of the knee injury and at risk
of falling again. Older patients are fearful of falling, and
after a fall, such as our patient had, they will stay in bed
to prevent a reoccurrence. This puts them at risk for skin
breakdown, blood clots, and poor nutrition.
How many geriatric-specific changes did you identify
as you read this case study?
Submissions to this column are encouraged and may be sent to
Joan Somes, RNC, PhD, CEN, CPEN, FAEN
somes@black-hole.com
or
Nancy Stephens Donatelli, RN, MS, CEN, NE-BC
question4gene@gmail.com

JEN is calling for EMS articles from personnel with experience in EMS. Please contact Joseph Kilpatrick, EMS Section Editior,
at rnnuke@aol.com for additional information or to discuss possible articles for submission.

262 JOURNAL OF EMERGENCY NURSING VOLUME 36 • ISSUE 3 May 2010

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