讀書報告 Assessment and management of the geriatric patient

1. 讀書報告Assessment and management of the geriatric patient 報告人：張正玉 護理師 日　期：96.2.26

2. Outline • Age-related physiologic changes • Preoperative assessment • Intraoperative management • Postoperative management

3. Age-related physiologic changes • Cardiovascular system • Respiratory system • Body composition and energy use • Central nervous system • Gastrointestinal system • Renal and G-U system • Musculoskeletal system • Immunologic system

4. 1. Cardiovascular system- I • Body compositon, metabolic rate and general state of fitness can affect heart performance. • Major vessels lose elasticity: SBP↑ • Left ventricular hypertrophy • Progressive valvular incompetence • Increased incidence of cardiac arrhythmias: tissue fibrosis→ conduction abnormalitis→SSS, atrial arrhythmias, and bundle branch block

5. 1. Cardiovascular system- II • Maximal heart rate, peak exercise cardic output, and peak ejection fraction↓ • Symptoms of MI in older patients: short of breath, syncope, acute confusion, or stroke.

6. 2. Respiratory system • anterior-posterior diameter of the chest, kyphosis and thoracic wall rigidity • residual volume • in the strength of the respiratory muscles • vital and total lung capacity • Ventilation-perfusion mismatch • Pulmonary damage: smoking, COPD

7. 3. Body composition and energy use • Increase in body fat and decrease in lean body mass • Daily energy expenditure decrease, acute illness or injury→ resting energy expenditure and O2 consumption↑ →support cardiopulmonary work, tissue repair and host defense • Serum albumin level ↓and hepatic function↓→ impairing adequate endogenous protein synthesis→ protein-energy malnutrition • Deficits in vitamins and trace elements • Fat

8. 4. Central nervous system • Neuronal density and nerve conduction decrease with age, sensory perception↓ • Thermoregulatory mechanisms may be compromised( In the post injury period, febrile responses may be blunted.) • Stress of surgery or acute illness can cause cognitive decline and delirium • Postoperatice pain control may be more difficult( a slight increase in pain threshold)

9. 5. Gastrointestinal system • G-I function is well preserved with healthy aging, and the absorption of most nutrients is unchanged with age. • Oral mucosa atrophy, periodontal disease, decayed teeth • Calcium absorption falls significantly • Colonic motility is not affected by aging, opioid receptors↑

10. 6. Renal and G-U system • Decreased glomerular filtration rate • Renal blood flow decreased, Ccr.↓ • Diminished capacity to regulate fluid and acid-base balance • Urinary incontinence, prostatic hypertrophy impairs bladder emptying • Female: estrogen↓→ urocystitis, UTI • Male: testoseron↓→ libido↓

11. 7. Musculoskeletal system • Skeletal muscles become smaller and weaker • Osteoporosis • Osteoarthritis

12. 8. Immunologic system • Increased risk of infection • Elderly patient with major infections frequently have normal WBC but differential count will show a profound shift to left, with a large proportion of immature forms. • Increase in autoantibodies

13. Preoperative assessment • Functional assessment • Nutritional assessment • Cognitive assessment

14. 1. Functional assessment • ASA physical status classification • The ability to perform the activities of daily living( e.g. feeding, transferring, toileting, dressing and bathing) has been correlated with post op mortality and morbidity. • Limited preoperative functional capacity may be associated with chronic anemia ( the prevalence ↑ after age 65) • Early mobilization is essential to limit all postoperative complications

15. 2. Nutritional assessment • Poor nutrition is a risk factor for pneumonia, poor wound healing, and other postoperative complications. • Factors associated with inadequate intake and use of nutrients include: • Ability to get food • Desire to eat food • Ability to eat and absorb food • Medications that interfere with appetite or nutrient metabolism • Serum albumin level ( <3.3mg/dL) • Subjective global assessment (SGA)

16. SGA (SubjectiveGlobal AssessmentScoring Sheet)

17. SGA (Subjective Global Assessment Scoring Sheet)

18. 3. Cognitive assessment • Postoperative delirium: a transient organic mental syndrome characterized by a global disorder of attention and cognition, reduced level of consciousness, abnormal psychomotor activity, and disturbed sleep-wake cycles. • Risk factors for delirium Age, Preoperative cognitive impairment , Poor functional status, Alcohol use, Use of multiple medications, Baseline dementia • Simple strategies for assessing mental status: the ability to remember and recall 3 objects after a short delay →if normal, a formal MMSE test

19. Intraoperative management • [beta]-Adrenergic Blockade: to decrease the incidence of postoperative cardiac complication. • Hypothermia • Fluids( CVP:8-10, PAP:14-18 to maintain C.O.) • Deep Vein Thrombosis Prophylaxis: subc. Heparin, LMWH or warfarin, combine with compression devices

20. Postoperative management - I • Mechanical Ventilation: >70 y/o, COPD→ long term ventilator dependence 2. Hemodynamics( adequate iv fluid administration) 3. Nutrition( start early) 4. Pain( poor inspiratory effort, atelectasis and pneumonia, and immobility) - Opioids, PCA - NSAID(a dose-sparing adjunct to opioids ) ~ GI bleeding and renal complication

21. Postoperative management - II • Delirium( goal: to maintain orientation) -frequent visits from family members or volunteers -encourage mobility and assist with feeding -clocks, calendars, and sensory aids -minimize noise at night, sleeping aids -creating medication dosing schedule that do not awaken patients • Transfusion -Restrictive transfusion( B/T only for HB<7) has lower ICU mortality compared with those treated with a liberal transfusion strategy( B/T for HB<10, maintain 10-12mg/dL), particularly in patient aged<55 yrs with less severe illness. -Attempting to maximize O2 delivery by applying high transfusion may impair rather than improve outcome.

22. Reference • Resenthal, R. A., Kavic, S. M., 2004, Assessment and management of the geriatric patient, Critical Care Medicine,vol. 32(4), S92-S105. • Litwack, K., 2006, Adjusting Postsurgical care for older patents, Nursing, vol. 36(1), pp. 66-67.

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