Adult

Primary
Care
Guide
Table of
Contents
Author's Note 1
How to Use the Guide 2
Health Promotion of the older adult 3
Obtaining the History 8
Review of System (ROS) 12
Adult Physical Assessment 15
Immunization of Adults 19->65 20
Presenting an Adult Patient 21
Diabetes 24
COPD 28
UTI 33
Hypertension 38
Hyperlipidemia 42
Conclusion 47
Notes 48
References 51
 Author’s note
Welcome to your Primary Adult Care Handbook! My name is Dr.
Sandra Pagenta, DNP, APN-BC. I am a board-certified Adult Nurse
Practitioner, and caring for adults is my specialty. I love the age
group of 65 and older in particular.

Taking care of adults is something I knew I wanted to do with my

career from the time I went to Nurse Practitioner school. I currently
work with an older population and there is nothing more wonderful
than one of my patients telling me I changed their life in regards to
their health choices.

I have 15 years of clinical nursing experience. I have worked in

various fields including Oncology, Neurosurgery, Radiation,
Gastroenterology, and Urology. I am also a podcast host, content
creator, and speaker. Additionally, I have served as an adjunct
professor and preceptor for many years. Looking back on my
clinical rotations, there were little to no resources available to
assist new NP students in adjusting to the expectations of the
clinical setting.

We hope these resources enrich your clinical experience and

provide opportunities beyond your clinical rotation!

DR. SANDRA PAGENTA,

DNP, APN-BC

1
 How to use
this guide
This notebook was designed to help you get the most out of your
clinical rotation in Adult Primary Care. We hope this serves as a quick
reference for you to glean the most from your clinical experience.
We have also included information on common medical diagnoses
that you will encounter. We hope you walk away with a favorable
clinical experience, clear goals on career aspirations, and new skills in
your practitioner repertoire!

Here is what you can expect to learn from

this guide:
Health promotion for older adults and immunization schedule.

Obtaining an HPI, ROS and performing a physical exam of an adult

patient and an older adult.

Presenting an older patient case to your preceptor.

How to diagnose and treat common disease processes in the older

adult.

2
 Health promotion
of the older adult
A society in which all people can
achieve their full potential for health
and well-being across their lifespan.

-Vision of Healthy People 2030

In 2019, 54.1 million US adults were 65 or older,

representing 16% of the population—or more
Did you than 1 in every 7 Americans. In 2026, when
know? post-World War II baby boomers begin to reach
age 80, estimates suggest that more than 20%
of Americans (almost 80 million) will be over 65.
(Stefanacci, 2022).

Aging refers to the inevitable, irreversible decline in organ function

that occurs over time even in the absence of injury, illness,
environmental risks, or poor lifestyle choices.

While there is no set age to define older age, any age above 65 is
often used as this is the age that determines eligibility for Medicare
insurance in the US.

3
Life expectancy for men is an additional 17 years at age 65 and 10
years at age 75; for women, it is an additional 20 years at age 65
and 13 years at age 75.
(Stefanacci, 2022).

Ageism refers to the prejudice towards people of an older age. This

is based on negative misconceptions and stereotypes and may be
overt or subtle.

Healthcare providers perpetuate age bias by not offering a treatment

to an older adult based on their age rather than on factors such as
expected life expectancy, quality of life, and patient preference.

Aging increases the risk of chronic diseases such as dementia, heart

disease, type 2 diabetes, arthritis, and cancer. The risk of Alzheimer’s
disease and other dementias increases with age, and these conditions
are most common in adults 65 and older.

Working with the older population, you

have to remind yourself of the
quality of life and life expectancy
when providing care. I counsel
patients from this lens a lot and
keep them from doing unnecessary
procedures/testing. They appreciate
that viewpoint, but I always offer
the treatment so they know their
options.

4
 Six in ten Americans live with at least one
Did you chronic disease, like heart disease and stroke,
know? cancer, or diabetes.

Avoiding Tobacco
and limiting
Avoiding second-hand Eating Well
Illicit Drugs smoke

Primary
Excessive
Drinking Prevent Prevention -
stopping disease
chronic before it starts

illness
Being Physically
Active
Regular Health
Screenings
Secondary
Prevention - detect and treat
disease or complications at an
early stage before symptoms or
functional loss

5
4 Domains of Chronic Disease Prevention
by the CDC

1. Epidemiology and Surveillance

Birth and death certificates, registries of cancer, and death.
Measuring social and environmental factors that influence
health.
Tracking policies that affect chronic disease, i.e. water
fluoridation.
Measuring the number of Americans who get health care
prevention.
Using technology to improve public health surveillance.

2. Environmental Approaches
Promoting health and supporting healthy behaviors in
worksites, and schools.
Banning flavored cigarettes, and passing smoke-free air laws.
Increasing prices for unhealthy products (e.g., low-nutrition
foods).
Designing communities to encourage walking and biking.

6
3. Health Care System Interventions
Improving access to healthcare for populations with little or
no access.
Paying for health outcomes instead of health services.
Increase of health information technology and tools.
Improving access to cancer screening for people with no or
little insurance.
Improving management of high blood pressure with
team-based care.

4. Community Programs Linked to

Clinical Services

Linking patients with chronic disease or with risk factors to

community resources such as Diabetes Prevention Programs,
and smoking cessations services.
Educating people to get more involved in their own
healthcare.

7
 Obtaining a history
Chief complaint
Include the primary symptom causing the patient to seek

1 care. Use the patient's own words.

If the patient is not the source, share who is providing the
information.
If the patient is not considered reliable, explain why (e.g.,
“somnolent” or “intoxicated”).

History of Present Illness

Think “OLDCARTS”

2 O - Onset
L - Location
D - Duration
C
A
R
-
-
-
Characterization
Aggravating Factors
Radiation
T - Temporal Factor
S - Severity Pain Scale

Past Medical History

3 First, list medical conditions and then provide the date of

onset, associated hospitalizations, complications, and if
relevant, treatments.
Surgical history with dates, indications, and types of
operations.
Obstetric and gynecologic history (GPAL): number of
pregnancies, number of live births, number of living
children, menstrual history and menopause, birth control.
continues
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 Psychiatric history with dates, diagnoses, hospitalizations,
and treatments.
Age‐appropriate health maintenance (e.g., pap smears,
mammograms, cholesterol testing, colon cancer) and
immunizations.
Describe any significant childhood illnesses.

Medications/Allergies

4 For each medication include the dose, route frequency,

and generic name.
Any over-the-counter (OTC) medications, medicinal herbs,
topical drugs, or dietary supplements.
Allergies: List the nature of the reaction.

Family History

5 List the health state or cause of death of parents, siblings,

and children. Record in particular if the patient has a family
history of HTN, CAD, CVA, DM, cancer, or alcohol abuse.
Use a family tree if possible.

Social History

6 Occupation.
Highest level of education, home situation, and
significant others.
Tobacco, alcohol, or other drug use, ETOH misuse
screening test for older adults: Short Michigan Alcohol.
Screening Test-Geriatric Version (or SMAST-G).
Sexual history: Note any safety concerns by the patient
(domestic violence, neglect).
9
 Advance directives (e.g., living will and/or health care
power of attorney).
Consider documentation of any important life experience
such as military service, religious affiliation, and spiritual
belief.

Social History

7 Inquire about:
Any special diets.
Intake of dietary fiber.
Weight loss and change of fit in clothing.
Amount of money patients have to spend on food.
Accessibility of food stores and suitable kitchen facilities.

Consider in Elderly:
Patient's ability to eat (e.g., to chew and swallow) is
evaluated.
Dry mouth.
Any changes in taste or smell as it may reduce the
pleasure of eating.
Decreased vision, arthritis, immobility, or tremors may
have difficulty preparing meals.
Urinary incontinence may inappropriately reduce their
fluid intake, increasing their risk of dehydration.

Functional Status

8 Assess the patient’s functional status – the ability to

complete the activities of daily living or consider using the
Modified Katz Acitivies of Daily Living Scale or Lawton
Instrumental Acitivies of Daily Living Scale.
10
Pro Tip
Fear of hospitalizations, difficulty recalling past medical history,
and atypical manifestations of a disorder make the history
taking of older adults more difficult.
Be aware of these challenges.

11
 Review of systems (ROS)
Constitutional Eyes
Weight gain/loss Blurry vision
Fatigue Diplopia
Fever/chills Eye pain/discharge
Night sweats Decreased visual
Anorexia acuity

ENT Skin
Frequent colds Rashes
Sore throat Hives
Sneezing Problems with hair
Stuffy nose Skin texture of color
Discharge
Postnasal drip
Mouth breathing
Pulmonary
Snoring Dyspnea
Otitis Wheezing
Hearing Cough
Adenitis Sputum
Hemoptysis
Cyanosis
Cardiovascular
Chest pain PND
Psychiatric
Palpitations Edema
Orthnopnea Claudication Anxiety
Insomnia
Dysphoria
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Gastrointestinal Genitoruinary
Nausea/vomiting Dysuria
Dyspepsia Frequency
Constipation Polyuria
Change in stools Pyuria
Tenesmus Hematuria
Hemorrhoids Urgency
Abdominal pain or discomfort Nocturia
Jaundice Incontinence
Testicular pain
Endocrine Dysmenorrhea
Menorrhagia
Disturbances of growth Genital lesions
Excessive fluid intake
Polyphagia
Goiter Neurologic
Thyroid disease Headache
Memory loss
Speech problems
Hematologic Syncope
Bruise easily Seizures
Difficulty stopping bleeds Numbness/sensory
Lumps under arms, neck changes
Tremor
Ataxia
Pro Tip Loss of coordination
Older patients may not report
Falls
symptoms that they may incorrectly
consider a part of normal aging.
However, no symptom should be
attributed to normal aging unless it
has been thoroughly evaluated and
other causes eliminated.
13
Common ROS findings in Geriatric Patient
Visual Auditory
Loss of near vision Hearing loss
Loss of central vision Loss of high-frequency
Loss of peripheral vision range (presbycusis)
Glare from lights at night
Eye pain
Gastrointestinal
Constipation
Cardiorespiratory Fecal incontinence
Difficulty eating or sleeping
Over-fatigue Gentiurinary
SOB
Orthopnea Urinary frequency,
Chronic cough hesitancy
Urinary incontinence

Neurologic/Psychiatric
Syncope
Extremities
Loss of power, sensation, or Leg and foot swelling
speech Leg pain
Persistent aphasia or dysarthria
distrubance of gait
Insomnia
Loss of memory extremities

Pro Tip
In older adults, typical manifestations of a disorder may be absent.
Instead, older patients may present with nonspecific symptoms
(e.g., fatigue, confusion, weight loss).

14
 Adult Physical
Assessment
Vital Signs: Height, Weight, Temp,
B/P, Pulse

Expected Findings
Normal Exam
in Older Adults

Well appearing, well

nourished, in no distress,
oriented x 3, normal
General
mood and affect,
ambulating without
difficulty.

Good turgor, no rash, Ecchymoses, Uneven

Skin unusual bruising, or tanning due to loss of
prominent lesions melanocytes

Normal texture and Thins, grays, and

Hair
distribution. becomes coarser

Normal color, no Longitudinal ridges on

deformities the nails and absence
Nails
of the crescent-shaped
lunula; nail plate fractures

15
 Head: Normocephalic, Face:
atraumatic, no visible • Eyebrows that drop
or palpable masses, below the superior
depressions, or scaring. orbital rim
Eyes: Visual acuity • Descent of the chin
intact, conjunctiva • Loss of the angle
clear, sclera non-icteric, between the
EOM intact, PERRL, fundi submandibular line and
have normal optic discs neck
and vessels, no exudates • Wrinkles
or hemorrhages. • Dry skin
• Thick terminal hairs
Ears: EACs clear, TMs on the ears, nose, upper
translucent and mobile, lip, and chin
ossicles nl appearance,
HEENT hearing intact. Ears:
• Excessive wax
Nose: No external formation
lesions, mucosa
non-inflamed, Nose:
septum and turbinates • Progressive descent
normal. of the nasal tip;
nosebleeds
Mouth: Mucous
membranes are moist, Eyes:
no mucosal lesions. • Loss of orbital fat,
Pseudoptosis
Teeth/Gums: No obvious (decreased
caries or periodontal size of the palpebral
disease. No gingival aperture)
inflammation or • Entropion (inversion
significant resorption. of lower eyelid margins)

16
 Pharynx: Mucosa • Ectropion (eversion
non-inflamed, no of lower eyelid margins)
tonsillar hypertrophy • Arcus senilis (a white
or exudate. ring at the limbus)
HEENT Neck: Supple, without Mouth:
lesions, bruits, or • Darkened teeth
adenopathy, thyroid • Xerostomia
non-enlarged and • Geographic tongue
non-tender

No cardiomegaly or Fourth heart sounds

thrills; regular rate and
Heart
rhythm, no murmur or
gallop.

Clear to auscultation
Lungs
and percussion

Bowel sounds normal, Weaker abdominal

no tenderness, muscles
Abdomen
organomegaly, masses,
or hernia

Spine normal without

Back deformity or tenderness,
no CVA tenderness

Normal sphincter tone, Susceptibility to

Rectal no hemorrhoids or constipation and
masses palpable, diarrhea

17
 prostate exam for size
(not a screening tool
for prostate cancer)

No amputations or Hallux valgus, bunion,

deformities, cyanosis, hammer toe
Extremities edema or varicosities,
peripheral pulses intact

Normal gait and station. Sarcopenia, some

No misalignment, decrease in coordination;
asymmetry, crepitation, shorter steps, reduced
defects, tenderness, gait velocity in patients;
masses, effusions, increased time in
MS decreased range of double stance, reduced
motion, instability, motion in joints; slight
atrophy, or abnormal changes in walking
strength or tone in the posture; tightening of
head, neck, spine, ribs, joints
pelvis or extremities

CN 2-12 normal. May lose vibratory

Sensation to pain, touch, sensation below the
and proprioception knees, due to spinal
normal. DTRs normal in cord sclerose; numbness
the upper and lower in feet due to decrease
Neurologic
extremities. No in size of fibers in the
pathologic reflexes. peripheral nerves;
information processing
and memory retrieval
slow but unimpaired.
18
 Oriented X3, intact
recent and remote
Psychiatric memory, judgment and
insight, normal mood
and affect.

Vagina and cervix Atrophy of the vaginal

without lesions or
discharge. Uterus and
Pelvic adnexa/parametria
nontender without
masses.
and urethral mucosa;
the vaginal mucosa
appears dry and lacks
rugal folds. Ovaries
should not be palpable
10 years after menopause

No nipple abnormality,
dominant masses,
Breast tenderness to palpation,
axillary or supraclavicular
adenopathy.

Penis: circumcised or
uncircumcised without
G/U:t lesions, the urethral
meatus normal location
without discharge,
testes and epididymides
normal size without
masses, and scrotum
without lesions.

19
 Recommended Adult Immunization Schedule by Age Group,
Table 1 United States, 2023

Vaccine 19-26 years 27-49 years 50-64 years >65 years

COVID-19 2- or 3- dose primary series and booster (See notes)
Influenza inactivated
(IIV4) or Influenza 1 dose annually
recombinant (RIV4)
Influenza live, 1 dose annually
attenuated (LAIV4)
Tentanus, diphtheria, 1 dose Tdap each pregnancy; 1 dose Td/Tdap for wound managment (see notes)
pertussis (Tdap or TD) 1 dose Tdap then Td or Tdap booster every 10 years
Measles, mumps, 1 or 2 doses depending on indication For healthcare personnel,
rubella (MMR) (if born in 1957 or later) see notes
Varicela (VAR) 2 doses (if born in 1980 or later)
Zoster recombinant 2 doses for inmmunocompromising 2 doses
(RZV) conditions (see notes)
2 or 3 doses
Human depending on age at 27 through 45 years
papillomavirus (HPV) initial vaccination or
condition
Pneumococcal 1 dose PCV15 followed by PPSV23 See notes
(PCV15, PCV20,
PPSV23) OR 1 dose PCV20 (see notes) See notes

Hepatitis A (HepA) 2, 3 or 4 doses depending on vaccine

Hepatitis B (HepB) 2, 3 or 4 doses depending on vaccine or condition

19 to over 65 years of age

Meningococcal A, C,
1 or 2 doses depending on indication, see notes for booster recommendations
W, Y (MenACWY)
Meningococcal B 1 or 2 doses depending on vaccine and indication, see notes
Immunization schedule-

19 through 23 years
(MenB) for booster recommendations
Haemophilus 1 or 3 depending on indication
influenza type b (H ib)
Recommended vaccination for adults who meet age Recommended vaccination for adults with an Recommended vaccination based No recommendation/
requirement, lack documentation of vaccination, or additional risk factor or another indication on shared clinical decision-making Not applicable

20
lack evidence of past infection
 Presenting an Adult
Patient case
Now Let's Put It All in Practice...
You can gain valuable knowledge from presenting your patient to
your preceptor. It gives your preceptor an opportunity to help you
formulate a patient’s assessment and plan.
Example:
Start with the Chief
Complaint and then the HPI.
Begin with Patient's name,
age, sex, presenting concerns,
list of medical diagnoses,
current medication, and new
lab results pertinent to
concerns.
"I am constantly urinating doc."
Tommy is a 75-year-old, white, male
seen in the clinic with new onset of
urinary frequency, urgency, and dysuria
for 3 days. PMH: DM, BPH, and HLD.
Patient is on Metformin 1,000 mg BID,
Lipitor 40 mg PO daily, and Flomax 0.4
mg daily. The laboratory findings showed
a white blood cell count of 10 900/mm3,
a glucose level of 200 mg/dl, BUN level
of 23.7 mg/dl, and a creatinine level of
1.0 mg/dl. Urinalysis showed 2 þ
proteinuria, 1 þ glycosuria, 25–30 white
blood cells per high-power field, and
25–30 red blood cells per high-power
field. He was + for nitrites and leukocyte
esterase.
ROS is +urinary frequency, foul-smelling
urine, dysuria, and urgency.
21
 Example:
Concern #1:
History of present illness,
relevant physical exam
findings, and treatment plan,
and then ask questions of
your preceptor.
Concern #1 Symptoms of urinary tract
infection: UA concerning for UTI. Will
treat with abx, Bactrim DS 1 tab BID for
7 days. His UTI is complicated since he
is male and may have an obstructive
component from his enlarged prostate.
I want to obtain a culture to ensure
appropriate abx were ordered before he
leaves the clinic today.
On physical examination, the patient’s
temperature was 36.5 C and blood
pressure was 130/80 mmHg. The
abdomen was soft with mild suprapubic
tenderness.

Concern #2 Uncontrolled DM: Dx over

Example:

5 years ago, his Metformin dose was

increased from 500 mg BID to 1,000 mg
BID at his last visit. HgbA1C was 7.5% last
Concern #2: year. This will increase his risk of UTIs.
Repeat any other concerns I want to recheck his HgbA1C to see if
as time allows. Ask relevant this recent dose increase was enough.
He might require additional medications
questions
to help cover his blood sugars. I will also
assess what has changed in his diet to
cause the recent increase in his blood
sugars.
Am I missing anything?

22
 Example:
Other concerns: Will address his DM at
the next visit in 4 weeks and order
HGBA1C prior to visiting to discuss. No
follow-up of the UTI is needed if his
symptoms improve. The patient is to call
Then share your the clinic if his symptoms do not
improve.
assessment and plan with
Assessment and plan: The patient has a
your preceptor:
complicated UTI at this time which can
be attributed to his history of BPH and
DM. Can refer to urology if UTIs continue
and refer to endocrinology if diabetes
continues to be uncontrolled.

presenting your
Congrats on
patient!

23
 Diabetes Mellitus Type II
Definition:
a condition in which individuals
have an impairment in insulin
production and or insulin resistance.
Incidence:
Estimated 29.1 million Amerians have diabetes (9.3 of the population.

Predisposing Factors
• Body Mass Index greater than
or equal to 27.
• Physical inactivity.
• First-degree relative with type 1
or type 2.
• HgbA1C greater than or equal
to 5.7% impaired glucose tolerance
or impaired fasting glucose.
• PCOS.
• Native American, Hispanic,
Asian, African American, Pacific
Islander.
• Hypertension.
• HDL of 35 or less, and TG
greater than or equal to 250.
• Female, and history of
Gestational DM.
• History of CVD.

Common Complaints:
• Polyuria. • Lack of energy.
• Polydipsia. • Recurrent infections.
• Polyphagia. • Asymptomatic.
• Weight loss.

Physical Exam
• Observe overall appearance. • Oral exam: every 6 months.
• Complete fundoscopic examination: inspect feet with monofilament testing,
hands and fingers, and skin fold for erythema and insulin injection sites.
24
Diagnostic Testing
• Serum glycoylated HgbA1C of 6.5% or higher.
• Fasting glucose greater than or equal to 126 mg/dL; performed
every 3 years for patients 45 and older.
• Random plasma glucose greater than or equal to 200 with
symptoms of diabetes.
• Oral Glucose Tolerance Test after a 75-gram glucose load, 2-hour
plasma glucose greater than or equal to 200 mg/dL.

Differential Diagnosis
• Benign pancreatic insufficiency. • Acromegaly.
• Pheochromocytoma. • Hemochromatosis.
• Cushing Syndrome. • Somogyi pheomenon.
• Stress hyperglycemia.

General Interventions
1. Create goals with the patient and refer back consistently. Goals
centered on metabolic control and preventing complications.
2. Be aware of the honeymoon phase or remission that may last 3-6
months after initial diagnosis and treatment.
3. Treatment plan: 1. Exercise 2. Self-monitoring of glucose -
frequency, type, and continuous; can refer to diabetes educator
3. Psychosocial support r/t depression and family support.

Client Teaching
1. Educate on the pathophysiology of DM, procedures, medications,
and recognition of hypoglycemia.
2. Prevention for family members, consideration MediAlert tag.
3. Smoking cessation.

25
Pharmaceutical Therapy
1. If HgbA1C is less than 7.5%, lifestyle modifications alone and
reassessed in 3-6 months with repeat HgbA1C.
2. If HgbA1C is greater than 7.5% being medications, start an
exercise program, and nutrition plan.
A. Start Monotherapy Metformin, when on max dose, and if the
goal is not achieved in 3 months start the second medication
should be added.
3. Start insulin for clients presenting with glucose above 300 mg/dL
or HgbA1C of 10% or higher. Also to be considered in patients
who are failing 2-3 diabetic medications, or if the patient has
ketonuria.

Follow up
• Follow up appts based on the type of diabetes, age, client
complaints, any treatment changes, and complications.
• Hgb A1C every 3 months, the target of 8% for the elderly, and
micro/macrovascular complications.
• Goal BG: 80-120 mg/dL preprandial.
• Glucose of 180 mg dL 1-2 hours after meals.
• SBP 130/80 BP Goal for patients >18 y/o with CKD.
• Cholesterol: Less than 200 mg/dL.
• TG Less than 150 mg/dL.
• HDLs greater than 35 mg/dL.
• LDLs less than 100 mg/dL, 70 mg/dL if heart disease present.
• Follow-up testing: every 2 years exam by an ophthalmologist;
monofilament foot exam at each follow-up, flu vaccine, serum
creatinine, BUN, GFR, lipids, UA, and albuminuria.

26
Referrals
• Diabetic Ketoacidosis.
• Pediatric patients.
• Hyperosmolar hyperglycemic
nonketotic syndrome.
• Pregnancy.
• Acute complications r/t
retinopathy.
• Neuropathy at the time of
diagnosis.
• Persistent uncontrolled
diabetes.

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27
 Chronic Obstructive
Pulmonary Disease (COPD)
Definition/Pathogenesis
COPD: A progressive, chronic, expiratory airway obstruction due to
chronic bronchitis or emphysema.

Chronic Bronchitis
Chronic productive cough lasting 3 months during 2 consecutive
years after all causes of chronic cough have been excluded. Patho:
Chronic bronchitis leads to the narrowing of the airway caliber and
increases in airway resistance. Hallmark: mucous gland enlargement.

Emphysema
Abnormal, permanent enlargement (hyperinflation) and destruction
of the alveoli air sacs as well as the destruction of the elastic recoil.
Caused by smoking, most severe in the upper lobes.
Many patients have both types of airflow restrictions.
Also, COPD is considered for asthmatic clients who do not have
reversible airflow obstruction.

Incidence
An estimated 16 million Americans have COPD, and millions more
do not know they have it. It is the third leading cause of death in
the US. More common in men than women.

28
 Global Severity
Initiative of Airflow In patient
for COPD in with Symptoms
(GOLD) Limitation FEV1/FVC
staging in COPD <0.70:
criteria:

FEV1 80% Some sputum and

Gold 1 Mild
predicted chronic cough

SOB on exertion
50% FEV1<80%
Gold 2 Moderate
predicted
and chronic
symptoms

Dyspnea, reduced
30% FEV1<50% exercise tolerance
Gold 3 Severe
predicted and exacerbtions
effecting QOL

Dyspnea at rest,
FEV1 < 30%
Gold 4 Very severe
predicted
and chronic
respiratory failure

Pro Tip
14% of patients admitted for COPD exacerbation
diet within 3 months of admission

29
Predisposing Factors
• Cigarette smoking.
• Dust.
• Chemical fumes.
• Secondhand smoke.
• Air pollution.
• Alpha-1 Antitrypsin deficiency.
• Recurrent or chronic lower
respiratory infections or disease.
• Age.
Common Complaints
• Chronic cough and colorless
sputum, usually worse in the
morning.
• Dyspnea with exertion,
progressing to dyspnea at rest.
• Wheezing.
• Difficulty speaking or
performing tasks.
• Weight loss (decrease in
fat-free mass).

Physical Exam
• V/S: Increased respiratory rate increases r/t disease severity
• Inspection: Increased anterior-posterior chest diameter. Examine
lips, fingertips, and nose for cyanosis.
• Pursed lip breathing and use of accessory.
• Auscultate: Lungs for wheezes, vocal fremitus, and egophony;
absent ventricular lung sounds.
• Percus for hyperresonance and for signs of consolidation.
• Six-minute walk test.

Differential Diagnosis
• Asthma.
• Heart Failure.
• Bronchiectasis.
• Pulmonary Edema.
• TB.
• AAT.
• Cancer.

30
Diagnostic Test
• Spirometry is the gold standard for diagnosing COPD.
• PFTs are used to determine the severity and disease progression.
Perform before and after the patient uses the bronchodilator.
• Sputum culture.
• Pt younger than 40, AAT.
• ABG. • EKG. • PPD. • BNP.

Pro Tip
Finger clubbing is not characteristic of COPD

General Interventions Client Teaching

1. Smoking Cessation and avoid 1. Educate the patient on
secondhand smoke. participating in the plan of
2. Pulmonary Rehab. care and medication
adherence.
Pharmaceutical Therapy
1. GOLD Stage I: Influenza vaccine and SABA bronchodilators.
2. GOLD Stage II: Influenza vaccine and SABA bronchodilators
needed plus long-acting bronchodilator plus cardiopulmonary rehab.
3. GOLD Stage III: Influenza vaccine and SABA bronchodilators as
needed + long-acting bronchodilator plus cardiopulmonary rehab +
inhaled glucocorticoid steroids if the patient has repeat exacerbations.
4. GOLD Stage IV: Influenza vaccine and SABA bronchodilators as
needed + long-acting bronchodilator plus cardiopulmonary rehab +
inhaled glucocorticoid steroids if the patient has repeat exacerbations
+ long-term oxygen therapy (PaO2 to be less than 55 mmHG or
resting O2 to be less than 88 on room air). Target is 88-92%.
5. Pneumonia vaccine for patients 65 and older.
6. Antibiotics in acute exacerbations.

31
Follow up
• Acute exacerbation follow-up on the same day or the following day.
• Reassess stable, chronic COPD every 1-2 months depending on
the patient.
• Serial PFTs.
• Serum theophylline.
• Evaluate for osteoporosis.
• Evaluate patients on oxygen therapy every 1 to 3 months.

Referrals
• Refer to a pulmonary specialist for rehab.
• Registered Dietitian for weight loss.
• Referral to a pulmonologist to evaluate for surgical interventions
(bullectomy, lung volume reduction surgery, or transplantation).

32
 Urinary Tract
Infection (UTI)
Definition
UTI is an infection of the urinary bladder. At least 100,000 organisms
per mL of urine in an asymptomatic client or more than 100 per mL
of ruined with pyuria (>7 WBCs/mL in a symptomatic client.
2 types: upper and lower tract infections. Can also be uncomplicated
(healthy with a normal urinary tract system tx with antibiotics by
mouth) vs complicated (for those that are immunocompromised or
have altered urinary system and require IV antibiotics).

Incidence
Young men 15-50 rare; geriatric males be as high as in geriatric
females up to 15%.
More than 50% of women will have 1 UTI in their lifetime.

Pathogenesis
• Bacteria ascend from the perineum through the urethra.
• Women> Men due to the shorter urethra.
• Older women due to estrogen- mediated dilation of the urethra.
• Elderly males infections are related to problems with the prostate
and instrumentation.
• Gram-negative bacilli are the most common (80-90%) E. coli.
• Fecal floras colonize the periurethral area.
• Other pathogens: K pneumonia or P. mirabilis. S. Saprophyticus
(gram+ 10-15%)

33
Predisposing Factors
• Female. • Instrumentation.
• Pregnancy. • Sexual Intercourse.
• Poor hygiene. • Female with diabetes.
• Trauma. • Anomalies of the GU tract.

Common Complaints Physical Exam

• Burning on urination. • Palpate abdomen: kidneys,
• Frequency. masses; assess for suprapublic
• Cloudy or bloody urine. tenderness.
• Urgency. • CVA tenderness.
• The elderly may not have any
symptoms or present with fever,
incontinence, or mental confusion.

Diagnostic Test Differential Diagnosis

• Can be made based on HPI. • Vaginal or Pelvic infection.
• Urinalysis (UA): Clean catch • Prostatitis.
preferred. May need • Bladder Tumor.
catheterization in the elderly. • IC.
• Urinary Calculi.
• BPH.
• OAB.
• Endocarditis in recurrent UTI?.

34
Urinalysis
dipstick Abnormal Normal
findings

Cloudy = pyuria, pus,

Appearance blood cells, phosphate Clear
or lymph

Ammonia = Proteus Faint aromatic

Odor Offensive = infection; odor
also food related

Greater than 7.5 =

pH 4.6-7.5, normal is 6
infection

Specific 1.010 can indicate mild Normal is 1.005-

gravity dehydration 1.025

• Straw color: dilute

Color • Dark color concentrated: Normal is 1.005-
dehydrated 1.025
• Red/Red-Brown to bloody:
drugs, bleeding lesions
transfusion reaction
• Yellow-brown: bile duct
disease, jaundice
• Dark brown or black:
Melanoma or leukemia

Leukocyte
esterase/ Positive (+) Negative (-)
Nitrates
35
General Interventions
1. Treatment is aimed at identifying the underlying cause and
starting treatment as soon as possible.
2. Start antibiotics and continue even if the patient's symptoms
improve.

Pharmaceutical Therapy
1. Antibiotics: 3 days course for uncomplicated UTI. Longer 7-10
days if the patient has a complicated UTI.
2. Antibiotics should be based on urine culture. Empiric
antimicrobial therapy should cover all pathogens.
3. First line:
a. Macrobid 100 mg PO BID for 5 days or Bactrim DS 1 tab
PO BID for 3 days or Fosomycin 3 g PO in a single dose
with 3-4 oz of water.
4. Second line:
a. Ciprofloxacin 250 mg PO BID for 3 days or Cirpo XR 500 mg
PO BID for 3 days or Levaquin 250 mg PO BID for 3 days.
5. Urinary Analgesic.
a. Pyridium 100 to 200 mg TID for 1-2 days. Will turn urine
orange.
b. Vaginal estrogen for post-menopausal women with
urogenital atrophic changes.

Follow up
• Posttreatment UA/UC is not indicated.
• Have the patient return if symptoms due to not resolve at end of
treatment or if they reoccur within 2 weeks. Retreat with 7 days of a
different abx.

36
Referrals
•Consulting with a urologist is essential in all forms of prostatitis or
all but the most clear-cut cases of acute scrotum.

37
 Hypertension (HTN)
Definition
Your paragraph text AHA/ACC guideline defines HTN as SBP over
130 mmHG and DBP of 80 mmHG or a condition in which a person is
taking antiHTN medications.

heart.org/bpleves

Other Types of HTN Differential Diagnosis

• Reistant. • Primary HTN.
• Orthostatic. • Secondary HTN.
• Nocturnal BP. • Drug induced.
• Isolated systolic HTN. • White Coat Syndrome.
• Isolated diastolic HTN.
• Malignant HTN.

Incidence
Affects 975 million people. 1 in 3 adults in the US, has HTN. High BP
was a primary or contributing case of death for more than 410,000
Americans in 2014. There are more than 1,100 deaths per day.
38
Pathogenesis
More than 90% of cases have no identifiable cause, constituting the
category of primary HTN. The remaining 10% have a secondary
cause: renal, endocrine, vascular, medication, or OSA.

Predisposing Factors
• BP Reading + family history, obesity, alcohol consumption, stress,
sedentary lifestyle, African American, male, age greater than 30
years, excessive salt intake, medications, and drug use.

Common Complaints:
• HTN is asymptomatic in the majority of patients.

Physical Exam:
• Diagnosis of HTN is made after averaging two or more properly
measure reading at each of two or more visits after an initial screen.
Compare both upper extremes with the right-size cuff during the
first visit. Use the higher value of either SBP or DBP or either arm.
• Inspect for JVD, and auscultate PMI and bruits.

Diagnostic Testing
• HCT. • UA for proteinuria.
• LFTs LDH and uric acid. • GFR.
• CMP. • EKG.
• Lipids. • Potassium level if on ACE/ARB.
• Any other peritent testing.

Plan
General Interventions
1. Weight loss, a goal of 10 lbs.
2. Discontinue alcohol.
3. Stop smoking.
4. Increase exercise, 40 mins of
aerobic/3-4x a week.
5. Stress reduction.
39
Client Teaching
1. Stress the importance of ongoing monitoring and treatment under
a healthcare provider.
2. CardioSmart Patient Education Portal free resources.

Dietary Management
1. Low fat/low cholesterol and DASH diet.

Pharmaceutical therapy
1. If lifestyle changes are not enough consider drug therapy. The drug
therapy is based on the patient's age, ethnicity, and comorbidities.
2. ACEIs, ARBs, CCB, and thiazide diuretics should be used as
first-line options, single or in combination.
3. Start antihypertensives/diuretics in low doses and increase them if
there is an inadequate response.
a. Adding a second drug from another class; a diuretic if not
being used (may worsen gout and diabetes).
b. Beta-blockers are no longer first-line antihypertensive. But
can be used in patient switch CAD, post MI dysrhythmia.
Do not use in patients over 60 or those with asthma, HF,
and heart block. Short-acting BB, should not be stopped
abruptly, but taper.
c. ACEIs (may cause coughing) and ARBs are best in patients
with renal disease, diabetes, and proteinuria.
4. Evaluate the patient for other causes of HTN if resistant to therapy.
HTN is considered resistant when the patient is on 3 drug therapy.

Treatment protocol example (HTN >20 mmHg above goal:

• An ACE inhibitor or ARB with diuretic or a dihydropyridine, CCB
combination. Start low.
• Still not controlled: +DHP CCB or thiazide diuretics. Vasodilating BB
or aldosterone blocker. Alpha blockers and direct vasodilators. Then
refer. 40
Follow up
• If drug therapy is started see a patient in 2-4 weeks for a follow- up.
• Then once stable every 3-6 months.
• Evaluate yearly with uric acid, creatinine, and potassium.
• Review drugs at each visit.
• Blood pressure measuring at home with apps or log.
• Sleep study for OSA.

Referrals
• Consult physician if the patient is having an acute hypertensive
emergency; DBP greater than 130 mmHg. Or if the patient needs
more than 3 drugs for therapy.

41
 Hyperlipidemia
Definition
Hyperlipidemia (HLD) is an elevation in serum lipoproteins and a
major risk factor for the development of cardiovascular disease and
CVD.
Atherosclerosis is a systemic disease characterized by lipid deposition
and smooth muscle cell migration and proliferation in the time of the
large arteries. These changes lead to thrombotic stroke, PVD, ASCVD,
and MI.
Two lipids in the blood: Cholesterol (<200 GOAL) and Triglyceride
(TG) (<149 GOAL.
Cholesterol is composed of three components:
• HDL (high-density lipid-protein) greater than 60 negative risk
factors for CVD, less than 35 are a risk factor.
• LDL (low-density lipid protein)- 70% of cholesterol; GOAL <100;
greater than 160 mg/dL increased the number of cardiac events.
• VLDL (very low-density lipid protein)(this is where TG are found)
VLDL uncertain role in atherosclerosis, inverse relationship between
VLDL and HDL-C.

Incidence
Begins in childhood; increases with age. CVD causes 1 in 3 deaths
each year in the US. Claims more lives than all forms of cancer and
chronic respiratory disease combined. Cost of 316 billion dollars.
Leading factors for CVD are HTN, HLD, and smoking.

Pathogenesis
Atherosclerosis is in part attributed to the deposition of cholesterol
and lipoproteins in arterial smooth muscle cells.
Dietary factors, obesity, drugs, and genetic defects in lipoprotein

42
particle metabolism influence lipid and lipoprotein concentrations in
blood.
Primary hyperlipoproteinemias - genetic.
Secondary hyperlipoproteinemias - abnormal metabolic pathway.

Predisposing Factors
High-Risk Factors: • Elderly persons experience
• Clinical CVD. higher morbidity and mortality.
• Symptomatic carotid artery • Cigarettes.
disease. • Low HDLs.
• Peripheral arterial disease. • Family history of CAD.
• Abdominal Aortic Aneurysm. • HTN.
• Obesity.
Major Risk Factors • Diabetes.
• Age (strongest predictor). • Chronic inflammation.
• Greater than 45 for men and 55
for women.

Predisposing Factors
No common complaints. Detected by routine laboratory testing.

Physical Exam
• Insepct: Skin for xanthomas; Eyes for premature arcus cornealis.
• Palpate: Abdomen for splenomegaly/hepatomegaly; thyroid.
• Auscultate: heart sounds.

Diagnostic Testing
• Lipid profile. • Thyroid function.
• CBC. •CRP.
• CMP. • HgbA1C.

43
Look for Common Secondary Causes:
• DM. • Obesity.
• Hypothyroidism. • Obstructive Liver disease.
• Porphyria.

Plan
General Interventions
1. TLCs- exercse, diet and weight management.
2. Increase physical activity. 40 mins, 3-4x a week.

Dietary Management
1. Cholesterol lowering diet. Diet modification is the first line of
therapy.

Client Teaching
1. Weight reduction.
2. Quit smoking.
3. Reduce intake of saturated fats, increase fiber, limit alcohol, lower
sodium intake.

Pharmaceutical therapy
• Drug of choice HMG-CoA reductase inhibitors.
• Work by suppressing the activity of the key enzyme in cholesterol
synthesis in the liver; effective in lowering LDL. Use with:
a. Individuals with the presence of clinical ASCVD.
b. Individuals 40-75 y/o with diabetes and LDL 70-189 and
without ASCVD.
c. Individuals 40-75 y/o with LDL of 70-189 and a risk of
ASCVD of 7.5% or higher.
Be sure to check LFTs before, 4-6 weeks after starting drug therapy
and stop for any adverse symptoms or abnormal labs.
Treatment options are available on AHA/ACC online. 44
Non-
Lipid Side
Statin Agents
Effects Effects
Drugs

Cholestryramine LDL drop 15-30% • GI distress

(4-16 grams)
HDLs rise 3-5% • Constipation
Bile Acid Colestipol (5-30 TG no change • Decrased
grams)
Colesevelam absorption of
1875-3750 mg) other drugs

IR Nicotinic • Flushing
(1.5-3 g) LDL drop 5-25% • Hyperglycemia
Nicontinic ER Nicotinic HDLs rise • Hyperuricemia
15-35%
acid (500-2000 mg)
• GI distress
SR Nicotinic TG drop 20-50%
(1-2 g) • Hepatotoxicity

Gemfibrozil, LDL drop 5-20% • Dyspepsia

Fibric Acids Fenofibrate HDLs rise • Gallstones
10-20%
Clofibrate TG drop 20-50% • Myopathy

• Arthralgias
PCSK9 Alirocumab • Headache
LDL drop 43-64%
Evolocumab • Limb pain
• Fatigue

• Diarrhea
Cholestrol Ezetimbe
• Back pain
absoption (Zetia) 10 mg a LDL drop 13-20%
• Abdominal
inhibitor day
pain

45
Follow up
Measure total cholesterol 4 weeks after starting a diet, and then 3-4
month intervals.
If starting therapy, obtain fasting/nonfasting lipid panel, LFTs, and
CBC. Recheck 4-6 weeks after starting drug therapy. Then, every
6-12 months interval.

Referrals
Refer to a dietitian for nutritional counseling for dietary
modifications. Starting statin therapy in the elderly (>80) requires
serious discussion about the increased risk of side effects.

Credits: Di Drawing

46
Conclusion

I hope this workbook helps to enhance your learning

from your adult (geriatric) clinic rotation. Working with
this population is my favorite and I hope that my love
for this population came across in this booklet.

We need all types of NPs in healthcare, and if you

share my love for this population- we are kindred
spirits.

This population will be booming (no pun intended for

baby boomers) over the next five years and our
country needs Nurse Practitioners to care for this
incredible population. Go forth and provide great care!

l u c k !
Good
DR. SANDRA PAGENTA,
DNP, APN-BC

47
Notes

48
Notes

49
Notes

50
 References
• Recommended adult immunization schedule 2023 for ages 19
years or... - CDC. (n.d.). Retrieved March 21, 2023.
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-c
ombined-schedule.pdf

• McDonough, K. (n.d.). Review of Systems (ROS). The Foundations

of Clinical Medicine. Retrieved March 19, 2023.
https://uw.pressbooks.pub/fcmtextbook/chapter/review-of-system
s-ros/

• Lenartowicz, M. (2023, March 15). Prevention of disease in older

adults - geriatrics. Merck Manuals Professional Edition. Retrieved
March 21, 2023.
https://www.merckmanuals.com/professional/geriatrics/prevention-
of-disease-and-disability-in-older-adults/prevention-of-disease-in-
older-adults#v37581475

• Soap notes format in EMR - Florida State University College of

Medicine. (n.d.). Retrieved March 21, 2023.
https://med.fsu.edu/sites/default/files/userFiles/file/MedInfo_SOAP
note_Jobaid.pdf

• Centers for Disease Control and Prevention. (2021, April 28). How
we prevent chronic diseases and promote health. Centers for
Disease Control and Prevention. Retrieved March 21, 2023.
https://www.cdc.gov/chronicdisease/center/nccdphp/how.htm

51
• Fauziyah, S., Radji, M., & Andrajati, R. (2017). Polypharmacy in elderly
patients and their problems. Asian Journal of Pharmaceutical and
Clinical Research, 10(7), 44.
https://doi.org/10.22159/ajpcr.2017.v10i7.18548

• Stefanacci, R. G. (2023, March 15). Physical examination of the

older adult - geriatrics. Merck Manuals Professional Edition.
Retrieved March 21, 2023.
https://www.merckmanuals.com/professional/geriatrics/approach-t
o-the-geriatric- patient/physical-examination-of-the-older-adult

• Stefanacci, R. G. (2023, March 15). Introduction to geriatrics - geriatrics.

Merck Manuals Professional Edition. Retrieved March 21, 2023.
https://www.merckmanuals.com/professional/geriatrics/approach-t
o-the-geriatric-patient/introduction-to-geriatrics

• Cover story: The 2017 high blood pressure guideline: Risk reduction
through better management. American College of Cardiology. (2017,
November 15). Retrieved March 23, 2023.
https://www.acc.org/latest-in-cardiology/articles/2017/11/14/14/42/
the-2017-high-blood-pressure-guideline-risk-reduction-through-be
tter-management

• Cash, J. C. (2021). Family practice guidelines. Springer Publishing. 2017

ACC/AHA/AAPA/ABC/ACPM/AGS/apha/ash/ASPC/NMA/PCNA
guideline for the... (n.d.). Retrieved March 26, 2023.
https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

•Reading the New Blood Pressure Guidelines. Harvard Health. (2021,

November 16). Retrieved March 26, 2023.
https://www.health.harvard.edu/heart-health/reading-the-new-bloo
d-pressure-guidelines
52