Teaching About Atypical Presentations

8/8/2019 Teaching About Atypical Presentations

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ATYPICAL

PRESENTATIONS

IN OLDER ADULTS

If you think you know what

youre looking for, think again!(Amella, 2004)

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OBJECTIVES: THE LEARNER

Will be able to assess an older adult for atypical

presentation of disease(s)

Will be able to identify the clinical relevant signs

and symptoms of an atypical presentation of

Will be able to identify important resources to

help guide the nursing assessment of an older

adult believed to have an atypical presentation of

an illness

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NO SINGLE, CHRONOLOGICAL

TIMETABLE OF HUMAN AGING

EXISTS

One conclusion from a longitudinal study on

aging that has tracked individuals from age 20 to

over age 90

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ADDING TO THE CONFUSION

Older adults (over 65) take more medications

This polypharmacy leads to

a potential change in mental status

which may be mistakenly be attributed to old age

No Gold Standard definition exists

atypical signs and symptoms may occur in place of

other more traditional symptoms associated with the

disease

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GERIATRIC SYNDROME?

Early definition: conditions experienced by older

persons that occur intermittently rather than

continuously or a as a single episodes (1991)

Geriatric syndromes have been viewed as

result not solely from discrete diseases but also

from accumulated impairments in multiple

systems (1995)

It is multiple abnormalities that run together to

cause a single phenomenology (2003)

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Dr. J. Flacker (2003) proposes that

conditions are geriatric syndromes IF

They are multifactorial

Occur primarily in older persons And result from interaction between

identifiable patient-specific impairments

identifiable situation-specific stressors

and interventions improving the contributing factors

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Buffalo hump

Moon faceies

Truncalobesity

TRADITIONAL MEDICAL

SYNDROME

Syndrome

Skin thinning

Osteoporosis

Muscle

weakness

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Delirium

Dehydration

Dementia

Severity of

illness

THE GERIATRIC

SYNDROME

Sleep

disturbances

Older age

ensory

impairment

Medication

effects

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NURSING CARE OF OLDERADULTS

Complicated by physical changes of aging

and multiple medical problems

Nursing assessment is essential

Requires a recognition that the assessment

of acute, chronic and/or complex illness may

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present atypically

Early recognition can improve plans of care

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WHAT CONSTITUTESATYPICAL

PRESENTATION?

Atypical presentation of illness to include:

vague presentation of illness

altered presentation of illness

non-presentation of illness

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CLASSIC S/SXOFTEN PARTOF ANATYPICAL PRESENTATION

Acute confusion(for example delirium)

Failure to eat or

drink (for example,

Functional decline

Reduced mobility

Generalized

Signs and Symptoms Signs and Symptoms

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Failure to develop a

fever in light ofleukocytosis

Lack of pain with adisease known to cause pain

(such as gastric ulcer

disease)

weakness

Falling

Fatigue

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EXAMPLES OF CASE REPORTS OF ANATYPICAL

PRESENTATION OF DISEASE IN OLDERADULTS

Case reports of atypical presentation of diseases

among older adults

Pain is often an acute heralding feature associated

with the onset of many diseases but not in older

adults

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Gastrointestinal ulcer or reflux disease, myocardialinfarction or a urinary track infection most alwayspresents with pain among younger adults. Thesesame diseases occurring among older adults do nothowever, necessarily present with pain as amanifestation

Case Study

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EXAMPLES OF CASE REPORTS OF ANATYPICAL

PRESENTATION OF DISEASE IN OLDERADULTS

Older adults with acid-related diseases of the

gastrointestinal track pain reported was subtle, atypical or

absent

Older adult women with coronary heart disease, atypical

Case Study

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symptoms were present during the infarction

MIs in older adults can include vague and non-specific

symptoms such as minimal or no chest pain, no shortness

of breath or acute confusion

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CLASSIC ANDVARIANT SYMPTOMS

OFANACUTE MYOCARDIAL INFARCTION (MI)

Classis signs observedwith an MI

Atypical presentationof MI

Sub-sternal chest pain Mild or absent pain

Radiating pain to neck, jawor arm

Acute confusion

Shortness of

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breathe/dyspneaor a sen yspnea

DiaphoresisElectrocardiogram evidenceof infarction

No electrocardiogramevidence or Non-Q waveinfarction or silent

(no symptoms) Myocardial infarction14

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CLINICAL MANIFESTATIONS OF INFECTION IN

RESIDENTS OF LONG-TERM CARE

Typical findings of infectionAtypical findings of

infection

Fever Change in mental status

Clinical Manifestations of Infections:

Pertains to infections of the urinary tract, respiratory,

skin and soft tissue, gastrointestinal and/or bacteremia

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Cough and yellow sputum(respiratory infection)\

Change in cognition function

Heat, redness, purulence andskin breakdown (pressure soreinfected)

Decline in physical function ( forexample: inability to performactivities of daily living or newonset of incontinence, falling orfailure to cooperate inrehabilitation)

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CLINICAL MANIFESTATIONS OF INFECTION IN

RESIDENTS OF LONG-TERM CARE (CONT)

Typical findings ofinfection

Atypical findings ofinfection

Clinical Manifestations of Infections:

Pertains to infections of the urinary tract,

respiratory, skin and soft tissue, gastrointestinal

and/or bacteremia

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Erythemia and purulence ofeye (conjunctivitis)

Afebrile (15 percent ofbacteremic patients who areelderly are afebrile)

Tachypnea (respiratory rategreater than 25 breaths/minute)

Dehydration (clinical observationcoupled with laboratory assays

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The importance of recognizing the presence of an

atypical presentation and the range of possible

symptoms, can not be over stated: its an essential

consideration when caring for older adults.

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Older adults over age 85, those with multiple

comorbidites and medications, and those older adults

with cognitive or functional impairment are atgreatest risk for developing atypical presentation.

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Consequence of not recognizing atypical

presentation directly affects the delivery of quality

health care to older adults across all practice setting

At ical resentations are reco nizable

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Therefore must be identified in the nursing

assessment of an older adult on a consistent basis

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DETECTION OFATYPICAL

PRESENTATION

Detection contingent upon a thorough nursing

assessment.

1. Detection of an atypical presentation requires a

comprehensive, butproblem- focused history.

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3. It requires critical analysis of this data into adetermination of whether or not an atypical

presentation may exist.

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THE PROBLEM-FOCUSED HISTORY

In the history, detection of atypical presentations of

disease require nurses tofirst modify their standard

selection of questions asked to elicit a particular

problem by, thinking beyond the classic symptomsassociated with a particular disease entity.

Because part of any atypical presentation may

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include alteration in level of consciousness and or

cognitive impairment, its very important that

history taking be obtained from reliable caregivers

or healthcare providers who can accurately report

the older adults recent history.

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When unable to report an accurate history and

caregivers are absent, review the medical

record or discuss with theprimary care

provider to create an accurate historical detail.

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part of an atypical presentation.

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Relay information obtained to

primary care providers for prompt

intervention.

In some clinical situations,

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management by the primary care

providers may rely on other

measures such as cardiac

enzyme assay to establish a

diagnosis.

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THE FOCUSED PHYSICAL EXAMINATION

Physical examination rests on observing or

actively looking for certain tell tale signs which

may be part of an atypical presentation

This includes changes in behavior such as

restlessness or a itation, anxiet and chan es in

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cognition

All of these signs are readily observable on physical

examination.

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DETERMINING IF ANATYPICAL

PRESENTATION EXISTS

Based on the presenting symptoms and/or

signs, the nurse caring for the older adult

begins to formulate an impression of whether

or not an atypical presentation exists or is

likel .

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PRESENTATION EXISTS

Vital signs may be taken more frequently

Core or rectal temperature may be more accurateand essential in determining the presence of

What you can do

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con ons suc as ypo erm a re a e obacteremia

Daily intake and output of oral fluids may berequired to rule out such conditions as dehydrationalong with other types of laboratory work-up such asserum electrolytes, BUN and creatinine

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PRESENTATION EXISTS

Nursing interventions for validating signs of

atypical presentation include generalmeasures such as:

more frequent vital signs

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a y n ta e an output

daily weights

observations for pain, function and behavior

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PRESENTATION EXISTS

Whenever an atypical presentation is

suspected, clinical judgment will guide

appropriate nursing intervention.

Atypical presentation can actually be a

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me ca emergency, as n e case o acu e

myocardial infarction, time is of the essence in

terms of selecting appropriate nursing

intervention.

Remember

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PRESENTATION EXISTS

Having a protocol available at a facility can assist

in the step-by-step approach to interventions, which

is often helpful in managing certain conditions.

Nursing care of the older adult will need to reflect

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interventions, whereby all interventions are

prioritized according to the medical stability of the

patient and nursing judgment.

Clinical practice guidelines provide useful

interventions for nurses when caring for an older

adult believed to have an atypical presentation,

provided that these guidelines address this issue.28

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CONCLUSION

When nurses caring for older adults

routinely detect and act upon important

signs and symptoms associated with atypical

presentation, important health outcomes can

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REFERENCES

Amella, E. J. (2004). Presentation of illness in olderadults.American Journal of Nursing, 104(10), 40-51.

Bradway, C. (2007). Atypical presentation in olderadults with complex illness. Paper presented atGeriatric Nursing Education Conference Institute:Portland, OR.

Carlson, D. S., & Pfadt, E. (2009). Clinical coach fore ect ve nurs ng care o o er a u ts. a e p a,PA: F.A. Davis.

Flacker, J. M. (2003). What is a geriatric syndromeanyway? Journal of the American Geriatrics Society,51, 574-573.

Flaherty, E., & Zwicker, D. (2005). Atypicalpresentation. Retrieved August 7, 2009 fromhttp://consultgerirn.org/topics/atypical_presentation/want_to_know_more

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Teaching About Atypical Presentations