Presentation on theme: "Lol wiw (Little old lady who is weary)"— Presentation transcript:
1Lol wiw (Little old lady who is weary) Presence regional ems systemSeptember Continuing Education
2ObjectivesOutline assessment findings that can be used to determine what could be wrong with a “little old lady who is weary”.Identify “20 questions” that could help generate a history to identify the source of the weariness.Suggest assessment tools that can help differentiate why this lady is weary.List as many possible reasons for her weariness as you can.
3Scenario You are called to the home of a 79 year old woman whose chief complaintis that she “feels weary”.What does that mean?It should strike fear in your heart!! Weary could mean anything!!
4Weary According to the dictionary weary is “Feeling excessively tired or fatigued”What is really going on?Is she just tired, or is there a serious problem?
5What could be going on?Assessing an elderly woman can be difficult for many reasons.The chief complaint may have nothing to do with the primary problem. Many elderly have:Vague complaints.Failure to report important symptoms.Multiple diseases going on concurrently.Altered response to illness.
6How can you quickly and efficiently determine what is really the problem? Assess for life threatening conditionsKeep in mind physiological changes of agingGood Primary and Secondary AssessmentFocused HistoryUse all tools available to rule out conditions
7Physiological changes with aging Changes from aging canmake assessment confusing.mask a real physiological problem
8What is aging?Loss of ability to adapt to change or stressors (anything that attacks the bodyLoss of ability to maintain a constant environment in the body (steady temperature, blood pressure etc)Loss of ability to fight off disease
9Aging – same way a car ages Deterioration of connective tissuesArteries and veins –like hoses and pipes in a carSkin – body of the carBones – frame of the carFat – upholsteryLigaments, tendons, cartilage – shocks and suspension (anything made of plastic or rubber)
11Physiologic Changes Skin Susceptible to injury; longer healing time SensesDulling of the sensesRespiratory systemDecreased ability to exchange gases
12Physiologic Changes Cardiovascular system Increased risk of cardiovascular diseaseDeterioration of the electrical systemRenal systemDecline in kidney functionNervous systemMemory impairment, decreased psychomotor skills
13Physiologic Changes Musculoskeletal system Decrease in muscle mass and strengthGastrointestinal systemDecrease in ability of body to digest food properly
14Pathophysiology The body becomes less efficient with age. Decreased ability to recognize invading organisms and fight off infectionsThe elderly often suffer from more than one illness or disease at a time.The existence of multiple chronic diseases in the elderly often leads to the use of multiple medications.
15Patient Assessment All assessments are done using the same format: Scene size upGeneral ImpressionInitial Assessment (Level of consciousness, airway, breathing , circulation)Vital signsHistoryFocused assessmentHead to toe exam
16Scene Size UpBe keenly aware of the environment and why you were called.Scene safety should include looking for unsafe conditions.Look for hazards.Steep stairs, missing handrails, poor lighting, other fall hazards, loose rugs
17The general condition of the home will provide clues. Cleanliness, heat, lighting, appropriate food availableLook for signs of activities of daily living.Personal hygiene, getting dressed, food preparationScene size-up continues throughout call.How is she coping? Is it safe for her to return home?
18Scene Safety Assessment Questions Is the environment of the Little Old Lady’shouse safe for her to be in?Is the house in good repair?Is the house reasonably clean?Is the house reasonably uncluttered?Are the number of pets reasonable? Is the house free of pet odors?
19General Impressions/ Initial Assessment How does the LOL (little old lady) look?Sick or not sick?Never assume altered mental status is normal.May have to rely on family or caregiver to establish patient’s baseline LOCAssess the patient’s chief complaint and ABCs.
20Vital Signs Normal aging may affect physical findings. Increased BP, decrease pulse rates, irregular pulse rates, decreased and more shallow respiratory ratesChronic changes can mask acute problems.Ongoing assessments will help determine changes.Geriatric patients have decreased ability to compensate for illness
21Focused HistoryHistory is usually the key in helping to assess a patient’s problem.Begin with SAMPLEPatience and good communication skills are essential.Treat the patient with respect.Face the patient and speak in anormal tone to accommodate forhearing issues.
22Only experience and practice will allow you to distinguish acute from chronic physical findings in the elderly patient.Many times it takes “20 questions” to figureout what the problem is.
23Focused Exam /Head to Toe Exam Focused exam investigates area of chief complaintHead to toe exam of value because LOL is a poor historianShe may forget to tell you about a medical problem that she has had for a long time.She may not have “normal “signs and symptoms.
24Common Complaints Fatigue Fever Dyspnea Trauma Chest pain Falls Altered mental statusDizziness or weaknessFeverTraumaFallsGeneralized painNausea, vomiting, and diarrhea
25Before we go farther. . .How many physical problems can you think of that could make this Little Old Lady be WEARY?Can you think of 5 Problems?10 problems?More?
26Good tool to use to think of all possible problems: AEIOU TIPS Could it be? Alcohol, Alzheimer'sEpilepsy, Environment (too hot or too cold)Insulin (too much or too little)Opiates, OverdoseUremia (kidney failure)TraumaInfectionPsychosisStroke, Shock, Sepsis
28Neurological (head and Psychological) Possible Causes Altered Mental StateStrokeTransient Ischemic AttackSyncopePost IctalHead InjuryAbuseAlzheimer'sDepressionExhaustion
29Altered Mental StatusAcute onset is not normal in any patient even LOL (little old ladies).Most sudden changes are caused by a reversible condition.Evaluate and treat for hypoxia or hypoglycemia if present.
30Confusion is not normal!!! New onset confusion is a serious sign of a medical emergency!!
31Altered Mental Status Delirium Recent onset Usually associated with underlying causeThink “delirious with fever”DementiaDevelops slowly over a period of yearsAlzheimer's
32Change in altered mental status can denote serious underlying problems.
33What is a stroke? Disruption of blood flow to the brain Plaque Foreign debrisBroken vessel
34Transient Ischemic Attack “One Free Spin”Looks like a stroke but, symptoms improve in hoursTemporary disruption of blood flow to the brain -- Angina of the brainWarning signMimicked by low blood sugar30% of patients will have a true stroke in 30 days
35FAST Stroke (TIA) Assessment Modification of Cincinnati Pre-Hospital Stroke ScreenFaceArmSpeechTime of onset
36FACE Look for Facial Droop Have the patient smile or show his/her teethNORMAL Both sides of theface move equallyABNORMAL One side ofthe patient’s face droopsor does not move
37ARMSMotor Weakness: Look for arm drift by asking the patient to close eyes and lift armsNORMAL- arms remainextended equally or driftdownward equallyABNORMAL – One armdrifts down comparedto the other
38Speech Ask the patient to say “You can’t teach an old dog new tricks” NORMAL –Phrase repeated clearly and plainlyABNORMAL – Words slurred, abnormal or unable to speak
39Time of OnsetThe window of opportunity to effectively treat STROKE is 3 hours (180 minutes)May be extended to 4 ½ hoursNeed to know “ last known well”.Difficult whenPatient lives aloneWoke up with symptoms
40Syncope -- dizziness -- Fainting Can occur for many reasons in geriatric patientsStanding up too fastStraining to have bowel movementMyocardial infarctionDiabetic shockDehydrationIrregular heart beat
41Syncope A Sudden, Temporary Loss of Consciousness Assessment Cardiovascular causes.Dysrhythmias or mechanical problems.Non-cardiovascular causesMetabolic, neurological, or psychiatric condition.Idiopathic causes.The cause remains unknown even after careful assessment.Extended unconsciousness is NOT syncope.
42Seizures Generalized Seizures Post ictal: period of rest, sleep, or confusion after a generalized seizure event.
43Seizures vs syncope Differentiating Between Syncope & Seizure Bystanders frequently confuse syncope and seizure.
44sub Dural Hematoma Subdural Hematoma Bleeding within meninges Beneath dura materSlow bleeding from torn veinSigns progress over several daysSlow deterioration of mentationShrinking of brain tissue with age leaves space for hematoma to accumulateMay have fallen several days ago
45Psychiatric Emergencies Depression is common among older adults Physical pain, psychological distress, and loss of loved ones can lead to depression.Women are more likely to suffer depression.
46Exhaustion Normal fatigue Are you sick and tired of being sick and tired?
47Elder Abuse This problem is largely hidden from society. Definitions of abuse and neglect among older people vary.Victims are often hesitant to report an incident.Signs of abuse are often overlooked.
48Elder Abuse can come in several forms Physical AbuseFinancial AbuseEmotional AbuseIsolationNeglectMedical careMedicationsFood
49Assessment of Elder Abuse Chronic painSelf-destructive behaviorEating and sleeping disordersDepression or a lack of energySubstance and/or sexual abuse
51Neurological/Psychological Assessment questions Do you feel sad?Do you feel like you could hurt yourself?Do you feel like you are getting enough sleep?How long have you been feeling tired all the time?Have you been doing a lot lately? Have you been doing too much?Do you feel safe?Is anyone hurting you?Do you have what you need to survive?Can you smile and show me your teeth?Can you raise your arms like a sleepwalker?Can you say “you can’t teach an old dog new tricks”?When did this problem begin?Is the problem getting better? (Rule out TIA)Did you have a seizure?Have you had seizures before?Did you black out?Did you lose a chunk of time?Have you fallen in the last week or so?
52Pulmonary (Airway and Lungs) HypoxiaSleep apneaPneumonia
53Hypoxia Unable to take in enough oxygen to meet needs. Trachea and large airways increase in diameter.Decreased surface area of lungs as well as decreased elasticity in the lungs.Inhalation and coughing is less effective due to weakened chest wall and bone structures.Monitor hypoxia with pulse oximetryTreat if O2 < 94%Oxygen by cannula or mask
54Sleep ApneaCommon disorder of one or more pauses in breathing or shallow breaths during sleep.Breathing pauses can last from a few seconds to minutes up to 30 times or more an hour.Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.A chronic (ongoing) condition that disrupts sleep.the quality of sleep is poor, which makes the patient tired during the day.Sleep apnea is a leading cause of excessive daytime sleepiness.
55Pneumonia Infection of the alveoi and small bronchioles Alveoli fill with mucus and fluidSigns and symptoms:Looks illFever and chillsProductive coughChest pain with respirationSymptoms may be altered due to ageNo feverPoor cough
56Respiratory Assessment Questions Are you having trouble breathing?Do you feel short of breath?Do family tell you that your snore at night?Do you wake up tired?Do you have a cough?Do you cough anything up?What color sputum are you coughing up?Do you feel like you have a fever?Does it hurt to breathe?
58DysrhythmiasAbnormal heart rate/rhythms are often a cause of feeling tired and “weary”.Too fast rhythm (rate greater than 150 beats per minute)Too slow rhythm (rate less than 60 beats per minute)Irregular heart beats (atrial fibrillation or ventricular ectopy)
59Myocardial Infarction Signs and symptoms of myocardial infarction may be altered or absent.Silent MI with no chest painFatigue only symptomConfirm with 12 Lead EKG
60Congestive Heart Failure Early non-acute Congestive Heart FailureNo pulmonary edema during day light hoursShortness of breath and dyspnea at nightHolding extra body fluid in tissuesCourse rales/crackles in basesJugular Vein distentionAnkle edema
61Shock --- Perfusion issues DehydrationDrop in normal body water levels with agingPoor fluid intake (avoid going to the bathroom)No drop in blood pressure due to long term hypertension and hardening of arteriesNo tachycardia in response to fluid loss
62Orthostatic Vital Signs Check for dehydration with orthostatic vital signsTake BP and pulse whenlying flat, sitting and standingDrop in BP and increasein pulse with position change= hypoperfusion = shock
63Electrolyte Disorders Long term use of diuretics what pull salts out of bodyPoor replacement of salts through bodyLook for dry mucus membranesSodium (too high or too low)Potassium (too high or too low)No good way to check levels outside of lab tests in Emergency Department
64Anemia – insufficient Red Blood Cells Inadequate production of RBCAplastic anemiaIron deficiency anemiaPernicious anemiaSickle cell anemiaIncreased RBC destructionHemolytic anemiaRBC loss – bleeding from somewhere
65Cardiovascular Assessment questions Do your ankles swell?Are you thirsty?Do you feel dizzy when you sit up?Do you drink water? Do you take “water pills”?Do your lips/tongue feel dry?Have you had any bleeding? Vomiting blood? Bloody stools? Blood in urine?Does your heart race?Do you feel like your heart is beating too slow?Does your heart skip beats?Do you have chest pain? Jaw pain? Shoulder pain? Pain in your back?Do you have increased fatigue if you try to do something?Do you get congested at night? Do you have more difficulty breathing at night?
67PolypharmacyOlder people account for a large portion of overall medication usage.Many medications can have interactions or counter actions when taken together.Polypharmacy refers to the use of multiple prescriptions by a single patient.Too many doctors, too many pharmacies too many drugsPolypharmacy = 30% of geriatric hospital admissions
68OVerdose Common accidental overdoses: Tylenol® (Acetaminophen) Potentially fatal due to liver failureMixing over the counter and prescription pain medicationsCold medications
69OverdoseAccidental or intentional ingestion of prescription medications:Narcotics (slow heart rate and respirations, pinpoint pupils)Beta Blockers (slow heart rate and drop BP)Calcium Channel Blockers (slow heart rate and drop BP)Oral hypoglycemic medication (drop blood sugar)
70Overdose Exposure to chemicals Organophospate in “rose spray for aphids”Absorbs through skinSlow heart rate and low BPSLUDGE (salavation, lacrimatation, urination, diarrhea, gastric upset, emesis)Wash area of skin exposed
71Carbon Monoxide Poisoning Inhalation of gas that binds with hemoglobinAssessment/Associated SymptomsHeadacheIrritabilityErrors in judgmentConfusionVomitingFlu symptomsPink color
72Alcohol IntoxicationCould this LOL (little old lady) be intoxicated???Odor of alcohol on breath?Ethyl alcohol contained in elixirs and mouth washAlcohol can cause a drop in blood sugar
73Toxin Exposure Assessment Questions Have you been taking your medications the way they are prescribed?Do you have new mediations?Do you take over the counter medications in addition to your prescriptions?How much over the counter medication have you taken?Could you have taken too much medication?Have you been exposed to any chemicals in the last 24 hours? Cleaning, gardening?Do you have a smoke detector/CO detector?Is anyone else in the house feeling weary?Have you been drinking alcohol?Do you drink alcohol regularly?
74Infections/SepsisWith aging, the body’s immune system has more difficulty fighting off infections.The little old lady may have a system wide infection before she notices that she is sick.Frequently the source of infection is pulmonary (pneumonia) and urinary tract.
75Septicemia 90% fatalResults from presence of microorganisms or their toxic products in bloodstream --Patients may present with:Hot, flushed appearanceTachycardia and tachypneaHypotensionChills, cough
76Infection Assessment Questions How long have you been feeling bad?Have you had a fever? Chills ? Cough?Does it hurt to pee? Do you have burning or pain when you pee?Do you have to go to the bathroom frequently?
78Temperature of Environment Is the temperature in the Little Old Lady’s house appropriate for the weather outside? It is uncomfortably hot or cold?She may choose to not turn up the heat in winter or the air conditioning in summer due to cost.Older people have difficulty regulating body temperature and get hyper thermic and hypothermic easily.Does her skin have a normal temperature?
80Renal FailureElderly people are at greater risk for renal failure due to wear and tear to the kidney structuresRisk is compounded by diabetes and hypertension.
81Acute Renal Failure Assessment Change in urine outputSwelling in face, hands, feet, or torsoPresence of heart palpitations or irregularityChanges in mental function
82GI Bleeding (upper and Lower) Deterioration of gastric linings with ageIrritation of gastric linings due to use of over the counter pain medications such as Ibuprofen and Naproxen SodiumBlood in emesis or stoolsBlack tarry stoolsCoffee ground emesis
83May miss GI bleeding when taking vitamins with iron that can turn stools black Assess for signs and symptoms ofhypoperfusion – shock
84Abdominal Aortic Aneurysm Walls of the aorta weaken with ageMay leak before ruptureBleeding may be slow at firstLook for signs and symptoms of shock“Pulsing mass ‘ may be difficult to findMay complain of back pain more than abdominal pain.
85Acute AbdomenComplaints of abdominal pain in older patients usually indicate a serious event.Nervous system response to pain is lessened.Complaint may be only weaknessConsider gastrointestinal problems or abdominal aortic aneurysm.
86Malnourishment Is there food in the house? What has the patient been eating?How often has the patient been eating?Is there a problem with getting food?
87Gastrointestinal/GenitoUrinary Assessment Questions Have you had any problems going to the bathroom?Can you pee?Does your urine smell bad?Do your feet and hands swell?Do you have pain in your abdomen?Are you able to eat?Do you have nausea and/or vomitingDo you have diarrhea?Have you been vomiting blood? Black?Have your stools had blood in them? Black color?What have you been eating?Is there a problem getting food?Is there a problem preparing food?
88Review If doing this CE individually, please e-mail your answers to: Use “September 2014 CE” in subject box.IDPH site code: E-1214You will receive an confirmation. Print this confirmation for your records and document in your PREMSS CE record book.
89ReviewList 5 possible medical problems that could make this Little Old Lady weary.For each of the medical problems give at least 5 assessment questions to ask her.For each of the medical problem give at least 5 assessments to use to confirm your suspicions of the medical problem.List 3 EMS tools that would be of help to assess the Little Old Lady who is weary.