Geriatric Emergencies
Geriatric Emergencies
Introduction
Geriatrics involves assessing and treating diseases in individuals aged 65 or older.
Geriatric patients present unique challenges due to:
Chronic conditions
Multiple medications
Physiological changes associated with aging
Generational Considerations
Understanding and appreciating the life experiences of older individuals is crucial.
Interacting with older adults requires time and patience.
Treat all patients with respect, avoiding ageism.
Remember:
Not all older people have dementia.
Not all older people are hard of hearing.
Not all older people are sedentary or immobile.
Communication with Older Adults
Effective verbal communication skills are essential.
Communication techniques:
Speak respectfully and clearly.
Identify yourself.
Be mindful of your presentation.
Maintain eye contact.
Speak slowly and distinctly.
Have one person speak at a time, asking one question at a time.
Do not assume hearing impairment.
Allow ample time for responses.
Listen attentively.
Explain procedures before execution.
Common Complaints and Leading Causes of Death
The geriatric population is predisposed to problems not commonly seen in younger individuals.
Hip fractures are common, often due to weakened bones from osteoporosis or infection.
Sedentary behavior can lead to pneumonia and blood clots.
Changes in the Body
The aging process involves changes in physiological function across all tissues.
A decline in the functional capacity of organ systems is normal but impacts how patients respond to illness.
Changes in the Respiratory System
Age-related changes increase susceptibility to respiratory illnesses.
Changes include:
Weakened airway musculature
Enlarged alveoli with decreased elasticity
Slower chemoreceptor response
Decreased cough and gag reflexes
Pneumonia
Inflammation/infection of the lungs caused by bacteria, viruses, or fungi.
It is a leading cause of death from infection in Americans older than 65.
Aging causes immune suppression, increasing the risk of pneumonia.
Increased mucus production, pulmonary secretions, and infection impair alveoli's ability to oxygenate blood.
Management is the same as for any patient with pneumonia.
Pulmonary Embolism
Sudden blockage of an artery by a venous clot.
Patients present with shortness of breath and sometimes chest pain.
It can be confused with cardiac, lung, or musculoskeletal problems.
Risk factors include:
Living in a nursing home
Recent surgery
History of blood clots or heart failure
Presence of a pacemaker or central venous catheter
Obesity or sedentary behavior
Recent long-distance travel
Trauma, cancer, or paralyzed extremities
Presentation includes:
Tachycardia
Sudden onset of dyspnea
Shoulder, back, or chest pain
Cough
Syncope (in severe cases)
Anxiety, apprehension
Low-grade fever
Hemoptysis
Leg pain, redness, and unilateral pedal edema
Fatigue
Cardiac arrest (worst-case scenario)
Changes in the Cardiovascular System
The heart hypertrophies with age, and cardiac output declines.
Arteriosclerosis contributes to systolic hypertension.
Atherosclerosis
Geriatric patients are at risk for atherosclerosis.
It involves the accumulation of fat and cholesterol in the arteries.
Major complications include myocardial infarction and stroke.
Aneurysm
Older people have an increased risk of aneurysm formation, an abnormal dilation of a blood vessel wall.
Severe blood loss can occur if an aneurysm ruptures.
Blood vessels and heart valves can become stiff and degenerate, potentially leading to heart rates that are too fast, slow, or erratic.
Venous Stasis
Venous stasis is a vessel-related problem involving the loss of proper vein function in the legs, impairing blood return to the heart.
It can cause blood clots, and deep vein thrombosis (DVT) can lead to pulmonary embolism.
Patients typically exhibit edema in the legs and ankles.
Heart Attack
Classic heart attack symptoms may be absent in geriatric patients.
Silent heart attacks are common, especially in women and people with diabetes.
Manifestations of acute cardiac disease include:
Dyspnea
Epigastric and abdominal pain
Loss of bladder or bowel control
Nausea and vomiting
Weakness, dizziness, light-headedness, syncope
Fatigue or confusion
Other signs and symptoms:
Circulatory issues
Diaphoresis
Pale, cyanotic, or mottled skin
Abnormal or decreased breath sounds
Increased peripheral edema
Heart Failure
Symptoms differ based on whether the right or left side of the heart is failing.
Right-Sided Heart Failure
Fluid backs up into the body, causing:
Jugular vein distention
Ascites
Peripheral edema
Enlarged liver
Often caused by left-sided heart failure.
Left-Sided Heart Failure
Fluid backs up into the lungs, causing:
Pulmonary edema
Shortness of breath
Patients exhibit severe shortness of breath, hypoxia, and crackles in the lungs.
Paroxysmal Nocturnal Dyspnea
Sudden respiratory distress that awakens a person when reclining, caused by fluid accumulation in the lungs.
Patients report coughing, feeling suffocated, and cold sweats.
Tachycardia is usually observed.
Stroke
A leading cause of death in older individuals with preventable risk factors like smoking, hypertension, diabetes, atrial fibrillation, obesity, and sedentary lifestyle.
Uncontrollable factors include age, race, and gender.
Signs and symptoms:
Acute altered level of consciousness
Numbness, weakness, or paralysis on one side
Slurred speech, difficulty speaking
Visual disturbances
Headache and dizziness
Incontinence
Seizure
Hemorrhagic Strokes
Less common and more likely to be fatal.
Ischemic Strokes
Occur when a blood clot blocks blood flow to the brain.
Treatment aims to salvage surrounding brain tissue.
Transient Ischemic Attack (TIA)
Presents with similar signs and symptoms as a stroke.
Changes in the Nervous System
Common findings include changes in thinking speed, memory, and postural stability.
The brain decreases in weight and volume, with a 5% to 50% loss of neurons.
Sensory organ performance declines with age.
Vision
Visual acuity, depth perception, and light accommodation change.
Cataracts interfere with vision.
Decreased tear production leads to drier eyes.
Other changes:
Inability to differentiate colors
Decreased night vision
Inability to see up close (presbyopia)
Other diseases include glaucoma, macular degeneration, and retinal detachment.
Hearing
Changes in the inner ear make hearing high-frequency sounds difficult.
Problems with balance increase the likelihood of falls.
Presbycusis
Gradual hearing loss, mainly due to heredity and long-term exposure to loud noises.
Taste
A decrease in the number of taste buds can lead to:
Lessened interest in eating
Weight loss
Malnutrition
Complaints of fatigue
Touch
Decreased sense of touch and pain perception due to loss of end nerve fibers.
An older person may be injured without knowing it.
There is decreased sensation of hot and cold.
Dementia
Slow onset of progressive disorientation, shortened attention span, and loss of cognitive function.
It is a chronic, generally irreversible condition causing progressive loss of cognitive, psychomotor, and social skills.
Caused by neurologic diseases such as:
Alzheimer disease
Parkinson disease
Cerebrovascular accidents
Genetic factors
Assessment findings:
Short- and long-term memory loss
Decreased attention span
Inability to perform daily routines
Decreased ability to communicate
Confusion or anger
Impaired judgment
Inability to vocalize pain
Delirium
Sudden change in mental status, consciousness, or cognitive processes.
Marked by the inability to focus, think logically, and maintain attention.
Affects 15% to 50% of hospitalized people aged 70 years or older.
Acute anxiety may be present.
Generally results from a reversible physical ailment, such as tumors, fever, or metabolic causes.
In the history, look for:
Withdrawal from alcohol or sedatives
Medical conditions
Depression
Malnutrition or vitamin deficiencies
Environmental emergencies
Assess and manage the patient for:
Hypoxia
Hypovolemia
Hypoglycemia
Hypothermia
You may see changes in circulation, breath sounds, motor function, and pupillary response.
Syncope
Assume it is a life-threatening problem until proven otherwise.
Often caused by an interruption of blood flow to the brain.
Neuropathy
Disorder of the nerves of the peripheral nervous system.
Function and structure of peripheral motor, sensory, and autonomic neurons are impaired.
Symptoms depend on affected nerves and their location.
Changes in the Gastrointestinal System
Reduction in the volume of saliva, and dental loss occur.
Gastric secretions are reduced, and changes in gastric motility occur.
Incidence of certain diseases involving the bowel increases, and blood flow to the liver declines.
Age-related changes include:
Dental problems
Decrease in saliva and sense of taste
Poor muscle tone of the sphincter between the esophagus and stomach
Decrease in hydrochloric acid
Alterations in nutrient absorption
Weakening of the rectal sphincter
GI bleeding can be caused by inflammation, infection, or obstruction of the upper or lower GI tract.
Usually heralded by hematemesis
Bleeding that travels through the lower digestive tract usually manifests as melena.
Red blood usually means a local source of bleeding, such as hemorrhoids.
A patient with GI bleeding may experience weakness, dizziness, or syncope.
Specific GI problems in older patients include:
Diverticulitis
Bleeding in the upper and lower GI system
Peptic ulcer disease
Gallbladder disease
Bowel obstruction
When assessing patients, ask about NSAID and alcohol use.
Orthostatic vital signs can help determine if a patient is hypovolemic.
Treatment consists of airway, ventilatory, and circulatory support.
Acute Abdomen—Nongastrointestinal Complaints
Extremely difficult to assess in the prehospital setting.
The most serious threat from abdominal complaints is blood loss.
Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions.
Changes in the Renal System
Age brings changes in the kidneys, including:
Reduction in renal function
Reduction in renal blood flow
Tubule degeneration
Changes in the genitourinary system:
Decreased bladder capacity
Decline in sphincter muscle control
Decline in voiding senses
Increase in nocturnal voiding
Benign prostatic hypertrophy (enlarged prostate)
Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections.
Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise.
Urge incontinence is triggered by hot or cold fluids, running water, or thinking about going to the bathroom.
The opposite of incontinence is urinary retention or difficulty urinating.
In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult.
Bladder and urinary tract infections can also cause inflammation.
In severe cases of urinary retention, patients may experience renal failure.
Changes in the Endocrine System
Reduction in thyroid hormones (thyroxine) results in:
Slower heart rate
Fatigue
Drier skin and hair
Cold intolerance
Weight gain
Other endocrine changes include:
An increase in the secretion of antidiuretic hormone, causing fluid imbalance
Hyperglycemia
Increases in the levels of norepinephrine, possibly having a harmful effect on the cardiovascular system
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a type 2 diabetic complication in older people.
Assessment findings:
Warm, flushed skin
Poor skin turgor
Pale, dry, oral mucosa
Furrowed tongue
Signs of shock
The patient assessment should include:
Obtaining blood pressure
Distal pulses
Auscultation of breath sounds
Temperature
Assessment of blood glucose level (if permitted by local protocol)
Treatment should include airway, ventilatory, and circulatory support.
Changes in the Immune System
Infections are commonly seen in older people because of their increased risk.
They are less able to fight infections.
Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms.
Pneumonia and UTIs are common in patients who are bedridden.
Signs and symptoms may be decreased because of loss of sensation, lack of awareness, or fear of being hospitalized.
Changes in the Musculoskeletal System
Decrease in bone mass, especially in postmenopausal women, making bones more brittle and prone to fractures.
Joints lose their flexibility.
A decrease in muscle mass often results in less strength.
Changes in physical abilities can affect older adults’ confidence in mobility.
Muscle fibers become smaller and fewer.
Motor neurons decrease in number, which causes strength to decline.
Ligaments and cartilage of the joints lose their elasticity.
Cartilage goes through degenerative changes.
Osteoporosis
Characterized by a decrease in bone mass.
It causes reduction in bone strength and greater susceptibility to fracture.
Extent of bone loss depends on:
Genetics, body weight
Smoking, alcohol consumption
Level of activity, diet
Osteoarthritis
Progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs, and leads to joint stiffness.
Results from wear and tear and affects joints in the hands, knees, hips, and spine.
Changes in Skin
Proteins that make the skin pliable decline with age.
The layer of fat under the skin becomes thinner, and bruising becomes more common.
Sweat glands do not respond as readily to heat.
Pressure Ulcers
Also known as bedsores or decubitus ulcers, are a problem.
The pressure from the weight of the body cuts off the blood flow to the area of the skin, and with no blood flow, a sore develops.
Stages of ulcer development:
Stage I: Nonblanching redness with damage under the skin
Stage II: Blister or ulcer that can affect the dermis and epidermis
Stage III: Invasion of the fat layer through to the fascia
Stage IV: Invasion to muscle or bone
Toxicology
Older people are more susceptible to toxicity.
Kidneys undergo many changes with age.
Decreased liver function makes it harder for the liver to detoxify the blood and eliminate medications and alcohol.
Typical OTC medications can have negative effects when mixed with each other or with herbal substances, alcohol, and prescription medications.
Polypharmacy
Refers to the use of multiple prescription medications by one patient.
Negative effects can include overdosing and negative medication interactions.
Medication noncompliance occurs due to:
Financial challenges
Inability to open containers
Impaired cognitive, vision, and hearing ability
Depression
Not part of normal aging but a medical disease that is treatable with medication and therapy.
If depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population.
Risk factors include a history of depression, chronic disease, and loss.
The following conditions contribute to the onset of significant depression:
Substance abuse
Isolation
Prescription medication use
Chronic medical condition
Suicide
Older men have the highest suicide rate of any age group in the United States.
Older persons choose much more lethal means than younger victims.
They generally have diminished recuperative capacity to survive an attempt.
Common predisposing events and conditions include:
Death of a loved one
Physical illness
Depression and hopelessness
Alcohol abuse
Alcohol dependence
Loss of meaningful life roles
When assessing a patient displaying signs of depression, ask if he or she is considering suicide.
If the answer is “yes,” the next question should be, “Do you have a plan?”
Include this information in your report.
The GEMS Diamond
Created to help remember what is different about older patients but is not intended to be a format for the approach to geriatric patients or replace the ABCs of care.
Serves as an acronym for the issues to be considered when assessing every older patient:
Geriatric patient: Older patients may present atypically, so be familiar with the normal changes of aging.
Environmental assessment: The environment can help give clues to the patient’s condition and the cause of the emergency.
Medical assessment: Older patients tend to have a variety of medical problems and numerous medications, so thorough medical history is important.
Social assessment: Older people may have less of a social network and need assistance with activities of daily living, so consider obtaining information pamphlets about some of the agencies for older people in your area.
Special Considerations in Assessing a Geriatric Medical Patient
Assessing an older person can be challenging because of:
Communication issues
Hearing and vision deficits
Alterations in consciousness
Complicated medical histories
Effects of medications
Scene Size-up
Geriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities.
Many older people live alone, and access may be hampered if their condition prevents them from getting to the door.
Take note of negative or unsafe conditions.
Mechanism of injury/nature of illness may be difficult to determine in older people with altered mental status or dementia,
Ask the family member, caregiver, or bystander why he or she called.
Multiple and chronic disease processes may also complicate the determination of the NOI.
Chest pain, shortness of breath, and an altered level of consciousness should always be considered serious.
Primary Assessment
Address life threats and determine the transport priority.
Form a general impression to tell if the patient is generally in stable or unstable condition.
Use the AVPU scale to determine the patient’s level of consciousness.
Airway and Breathing
Anatomic changes that occur as a person ages predispose geriatric patients to airway problems.
Ensure that the patient’s airway is open and not obstructed by dentures, vomitus, fluid, or blood.
Anatomic changes affect a person’s ability to breathe effectively, and the loss of mechanisms that protect the upper airway causes a decreased ability to clear secretions.
Airway and breathing issues should be treated with oxygen as soon as possible.
Circulation
Poor perfusion is a serious issue in the older adult.
Physiologic changes may negatively affect circulation.
Vascular changes and circulatory compromise might make it difficult to feel a pulse.
Any complaints that compromise the ABCs should result in prompt transport.
Determine conditions that are life threatening, and treat them to the best of your ability.
Provide transport to priority patients.
History Taking
Investigate the chief complaint and find and account for all medications.
Obtain a thorough patient history.
Determine early whether the altered LOC is acute or chronic.
Multiple disease processes and multiple and/or vague complaints can make assessment complicated.
Collect a SAMPLE history, relying on a relative or caregiver to help if necessary.
List the patient’s medications or take the medications with you to the hospital.
The last meal is particularly important in patients with diabetes.
Transport to a facility that knows the patient’s medical history, if possible.
Secondary Assessment
Physical Examinations
An older patient may not be comfortable with being exposed, so protect his or her modesty.
Consider the need to keep your patient warm during the exam.
Vital Signs
The heart rate should be in the normal adult range but may be compromised by medications such as beta-blockers.
Weaker and irregular pulses are common.
Circulatory compromise may make it difficult to feel a radial pulse; consider other pulse points.
Blood pressure tends to be higher.
Capillary refill is not a good assessment.
The respiratory rate should be in the same range as in a younger adult, and be sure to auscultate breath sounds.
Carefully assess pulse oximetry data.
Reassessment
Reassess the geriatric patient often by reassessing vital signs and the patient’s complaint, rechecking interventions, and identifying and treating changes in the patient’s condition.
Communicate your findings and the interventions you used to emergency department personnel, and document all history, medication, assessment, and intervention information.
Geriatric Patient Assessment Guidelines:
When entering the home, take note of issues that would make it environmentally unsafe.
Introduce yourself, show respect, and use patience to gain an older patient's confidence.
Assessment of an older patient can be complicated by multiple medical or traumatic conditions, alterations in level of consciousness, and hearing and vision impairments.
Airway, breathing, circulation, and vital signs are changed by the normal process of aging.
Many older patients use multiple medications. Be aware of the possibility of overdose, underdose, and drug interactions.
An older person's body does not have the flexibility or reserves of a younger person's body when facing illness or injury.
Older people are more easily affected by poor nutrition.
Older people cannot thermoregulate easily and tend to be cold.
The memory and cognition of an older person may be impaired.
The skin of an older adult may be fragile and can tear easily. Consider patient transfer options that are safe and appropriate.
Trauma and Geriatric Patients
Conditions that create risk and complicate assessment:
Slower homeostatic compensatory mechanisms
Limited physiologic reserves
Normal effects of aging on the body
Existing medical issues
Physical findings in an older adult may be more subtle and easily missed, and mechanisms are much more minimal.
Recuperation from trauma is longer and often less successful.
Many injuries are undertriaged and undertreated.
Older pedestrians are more likely to have life-threatening complications after being struck by a vehicle and commonly suffer injury to the legs and arms, and secondary impacts can also cause serious injuries.
Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status.
Risk of mortality is increased when:
Preexisting medical conditions exist.
The immune system is weakened.
Fluid replacement is complicated by renal compromise.
Higher mortality from penetrating trauma in older adults, especially gunshot wounds.
Falls are the leading cause of fatal and nonfatal injuries in older adults, and nearly half of fatal falls in geriatric patients result in traumatic brain injury.
Anatomic Changes and Trauma
Changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma.
A geriatric patient’s overall physical condition may lessen the body’s ability to compensate for simple injuries.
Osteoporosis predisposes older people to hip and pelvic fractures due to:
Stresses of ordinary activity
A standing fall
Vitamin D and calcium deficiencies
Metabolic bone diseases
Tumors
With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle, causing compression fractures of the spine to occur.
Because brain tissue shrinks with age, older patients are more likely to sustain closed head injuries.
Acute subdural hematomas are among the deadliest of all head injuries.
Serious head injuries are often missed because the mechanism may seem relatively minor.
Other factors that predispose an older patient to a serious head injury include:
Long-term abuse of alcohol
Recurrent falls or repeated head injury
Anticoagulant medication
Environmental Injury
Internal temperature regulation is slowed, and half of all deaths from hypothermia occur in older people, including most indoor hypothermia deaths.
Death rates from hyperthermia are more than doubled in older people, and people older than 85 years are at the highest risk.
Special Considerations in Assessing Geriatric Trauma Patients
Trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient.
Scene Size-Up
Look for clues that indicate your patient’s traumatic incident may have been preceded by a medical incident, and bystander information may help.
MOI is important in establishing whether an injury is considered critical, and it affects treatment and transport considerations.
Primary Assessment
Address life threats and determine the transport priority and recommend that older trauma patients be transported to a trauma center.
Is the patient’s condition stable or unstable?
Use AVPU and the Glasgow Coma Scale to determine mental status.
Airway and Breathing
Older patients may have a diminished ability to cough, so suctioning is important.
Assess for the presence of dentures.
Circulation
Manage any external bleeding immediately.
Drinking alcohol and taking anticoagulant medications can make internal bleeding worse or external bleeding more difficult to control.
Older patients can more easily go into shock.
Patients who were hypertensive prior to injury may have a normal blood pressure when they are actually in shock.
History Taking
Investigate the chief complaint.
Considerations in your assessment must include past medical conditions, even if they are not currently acute or symptomatic.
Secondary Assessment
Physical examinations are Performed in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma.
Any head injury can be life threatening.
Check lung sounds and look for bruising and other evidence of trauma.
Vital Signs
Assess the pulse, blood pressure, and skin signs.
Capillary refill is unreliable because of compromised circulation.
Remember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic.
Reassessment
Repeat the primary assessment because a geriatric patient has a higher likelihood of decompensating after trauma.
Interventions
Interventions (cont’d)
Broken bones are common and should be splinted.
Do not force a patient with joint flexion or kyphosis into a “normal” position.
Provide blankets and heat to prevent hypothermia.
Communications and documentation
Communication can be challenging.
Provide psychological support as well as medical treatment.
Response to Nursing and Skilled Care Facilities
Many calls will occur at a nursing home or other skilled care facility and can be challenging because patients often have an altered level of consciousness, and staff may be spread thin and may not know how to assist you.
Ask, “What is wrong with the patient that is new or different today?”
Infection control needs to be a high priority for EMTs.
Methicillin-resistant Staphylococcus aureus (MRSA) infections are common.
Many infections in hospitals are caused by vancomycin-resistant enterococci.
The respiratory syncytial virus causes an infection of the upper and lower respiratory tracts.
Clostridium difficile is a bacterium responsible for the most common cause of hospital-acquired infectious diarrhea, and typical alcohol-based hand sanitizers do not inactivate or kill $C$ $difficile$.
SARS-CoV-2 affects older, more vulnerable people and spreads from person-to-person through airborne droplets created by speaking, coughing, and sneezing.
Dying Patients
More patients are choosing to die at home rather than in a hospital and receive palliative care.
Be understanding, sensitive, and compassionate, and determine if the family wishes for the patient to go to the hospital or stay in the home.
Advance Directives
Specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves.
May take the form of a do not resuscitate (DNR) order, which gives you permission not to attempt resuscitation for a patient in cardiac arrest, but DNR does not mean “do not treat,” and basic ABCs should still be provided.
Another type of order is the POLST (Physician Orders for Life Sustaining Treatment), which gives medical orders in addition to the advanced directives.
If there is any question regarding orders or when there are no written orders, initiate resuscitation.
Elder Abuse and Neglect
Any action on the part of an older person’s family member, caregiver, or other person that takes advantage of the older person’s person, property, or emotional state, including acts of commission and acts of omission
Has been largely hidden from society, and definitions of abuse and neglect among the geriatric population vary, and victims are often hesitant to report the problem.
The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse.
Elder abuse occurs more often in women older than 75 years, and abusers of older people are sometimes products of child abuse themselves.
Take note of the environment and conditions a patient lives in, and of soft-tissue injuries that cannot be explained by the person’s lifestyle and physical condition.
Suspect abuse when answers are concealed or avoided or when you are given unbelievable answers.
Information that may be important in assessing abuse includes:
Caregiver apathy about the patient’s condition
Overly defensive reaction by caregiver
Caregiver does not allow patient to answer questions.
Repeated visits to the ED or clinic
A history of being accident-prone
Unbelievable or vague explanations of injuries
Psychosomatic complaints
Chronic pain without medical explanation
Self-destructive behavior
Eating and sleep disorders
Depression or a lack of energy
Substance and/or sexual abuse history
Signs of Physical Abuse
Inflicted bruises are usually found on the buttocks and lower back, genitals, inner thighs, face, and ears.
Pressure bruises caused by the human hand may be identified by oval grab marks, pinch marks, or handprints.
Human bites are typically inflicted on the upper extremities and can cause lacerations and infection.
Typical abuse from burns is caused by contact with cigarettes, matches, heated metal, forced immersion in hot liquids, chemicals, and electrical power sources.
Check for signs of neglect, such as a lack of hygiene, poor dental hygiene, poor temperature regulation, and lack of reasonable amenities in the home.
Regard injuries to the genitals or rectum with no reported trauma as evidence of sexual abuse in any patient.
Geriatric patients with altered mental status may never be able to report sexual abuse.
Many women do not report cases of sexual abuse because of shame and the pressure to forget.