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Lol wiw (Little old lady who is weary)

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1 Lol wiw (Little old lady who is weary)
Presence regional ems system September Continuing Education

2 Objectives Outline 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.

3 Scenario You are called to the home of a 79
year old woman whose chief complaint is that she “feels weary”. What does that mean? It should strike fear in your heart!! Weary could mean anything!!

4 Weary 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?

5 What 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.

6 How can you quickly and efficiently determine what is really the problem?
Assess for life threatening conditions Keep in mind physiological changes of aging Good Primary and Secondary Assessment Focused History Use all tools available to rule out conditions

7 Physiological changes with aging
Changes from aging can make assessment confusing. mask a real physiological problem

8 What is aging? Loss of ability to adapt to change or stressors (anything that attacks the body Loss of ability to maintain a constant environment in the body (steady temperature, blood pressure etc) Loss of ability to fight off disease

9 Aging – same way a car ages
Deterioration of connective tissues Arteries and veins –like hoses and pipes in a car Skin – body of the car Bones – frame of the car Fat – upholstery Ligaments, tendons, cartilage – shocks and suspension (anything made of plastic or rubber)

10 Changes in the body systems of the elderly

11 Physiologic Changes Skin Susceptible to injury; longer healing time
Senses Dulling of the senses Respiratory system Decreased ability to exchange gases

12 Physiologic Changes Cardiovascular system
Increased risk of cardiovascular disease Deterioration of the electrical system Renal system Decline in kidney function Nervous system Memory impairment, decreased psychomotor skills

13 Physiologic Changes Musculoskeletal system
Decrease in muscle mass and strength Gastrointestinal system Decrease in ability of body to digest food properly

14 Pathophysiology The body becomes less efficient with age.
Decreased ability to recognize invading organisms and fight off infections The 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.

15 Patient Assessment All assessments are done using the same format:
Scene size up General Impression Initial Assessment (Level of consciousness, airway, breathing , circulation) Vital signs History Focused assessment Head to toe exam

16 Scene Size Up Be 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

17 The general condition of the home will provide clues.
Cleanliness, heat, lighting, appropriate food available Look for signs of activities of daily living. Personal hygiene, getting dressed, food preparation Scene size-up continues throughout call. How is she coping? Is it safe for her to return home?

18 Scene Safety Assessment Questions
Is the environment of the Little Old Lady’s house 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?

19 General 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 LOC Assess the patient’s chief complaint and ABCs.

20 Vital Signs Normal aging may affect physical findings.
Increased BP, decrease pulse rates, irregular pulse rates, decreased and more shallow respiratory rates Chronic changes can mask acute problems. Ongoing assessments will help determine changes. Geriatric patients have decreased ability to compensate for illness

21 Focused History History is usually the key in helping to assess a patient’s problem. Begin with SAMPLE Patience and good communication skills are essential. Treat the patient with respect. Face the patient and speak in a normal tone to accommodate for hearing issues.

22 Only experience and practice will allow you to distinguish acute from chronic physical findings in the elderly patient. Many times it takes “20 questions” to figure out what the problem is.

23 Focused Exam /Head to Toe Exam
Focused exam investigates area of chief complaint Head to toe exam of value because LOL is a poor historian She 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.

24 Common Complaints Fatigue Fever Dyspnea Trauma Chest pain Falls
Altered mental status Dizziness or weakness Fever Trauma Falls Generalized pain Nausea, vomiting, and diarrhea

25 Before 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?

26 Good tool to use to think of all possible problems: AEIOU TIPS Could it be?
Alcohol, Alzheimer's Epilepsy, Environment (too hot or too cold) Insulin (too much or too little) Opiates, Overdose Uremia (kidney failure) Trauma Infection Psychosis Stroke, Shock, Sepsis

27 OR Assess Head to Toe Assess by Body Systems

28 Neurological (head and Psychological) Possible Causes
Altered Mental State Stroke Transient Ischemic Attack Syncope Post Ictal Head Injury Abuse Alzheimer's Depression Exhaustion

29 Altered Mental Status Acute 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.

30 Confusion is not normal!!!
New onset confusion is a serious sign of a medical emergency!!

31 Altered Mental Status Delirium Recent onset
Usually associated with underlying cause Think “delirious with fever” Dementia Develops slowly over a period of years Alzheimer's

32 Change in altered mental status can denote serious underlying problems.

33 What is a stroke? Disruption of blood flow to the brain Plaque
Foreign debris Broken vessel

34 Transient Ischemic Attack
“One Free Spin” Looks like a stroke but, symptoms improve in hours Temporary disruption of blood flow to the brain -- Angina of the brain Warning sign Mimicked by low blood sugar 30% of patients will have a true stroke in 30 days

35 FAST Stroke (TIA) Assessment
Modification of Cincinnati Pre-Hospital Stroke Screen Face Arm Speech Time of onset

36 FACE Look for Facial Droop
Have the patient smile or show his/her teeth NORMAL Both sides of the face move equally ABNORMAL One side of the patient’s face droops or does not move

37 ARMS Motor Weakness: Look for arm drift by asking the patient to close eyes and lift arms NORMAL- arms remain extended equally or drift downward equally ABNORMAL – One arm drifts down compared to the other

38 Speech Ask the patient to say “You can’t teach an old dog new tricks”
NORMAL –Phrase repeated clearly and plainly ABNORMAL – Words slurred, abnormal or unable to speak

39 Time of Onset The window of opportunity to effectively treat STROKE is 3 hours (180 minutes) May be extended to 4 ½ hours Need to know “ last known well”. Difficult when Patient lives alone Woke up with symptoms

40 Syncope -- dizziness -- Fainting
Can occur for many reasons in geriatric patients Standing up too fast Straining to have bowel movement Myocardial infarction Diabetic shock Dehydration Irregular heart beat

41 Syncope A Sudden, Temporary Loss of Consciousness Assessment
Cardiovascular causes. Dysrhythmias or mechanical problems. Non-cardiovascular causes Metabolic, neurological, or psychiatric condition. Idiopathic causes. The cause remains unknown even after careful assessment. Extended unconsciousness is NOT syncope.

42 Seizures Generalized Seizures
Post ictal: period of rest, sleep, or confusion after a generalized seizure event.

43 Seizures vs syncope Differentiating Between Syncope & Seizure
Bystanders frequently confuse syncope and seizure.

44 sub Dural Hematoma Subdural Hematoma Bleeding within meninges
Beneath dura mater Slow bleeding from torn vein Signs progress over several days Slow deterioration of mentation Shrinking of brain tissue with age leaves space for hematoma to accumulate May have fallen several days ago

45 Psychiatric 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.

46 Exhaustion Normal fatigue
Are you sick and tired of being sick and tired?

47 Elder 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.

48 Elder Abuse can come in several forms
Physical Abuse Financial Abuse Emotional Abuse Isolation Neglect Medical care Medications Food

49 Assessment of Elder Abuse
Chronic pain Self-destructive behavior Eating and sleeping disorders Depression or a lack of energy Substance and/or sexual abuse

50 Hot Line Number for Elder Abuse
In Illinois

51 Neurological/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?

52 Pulmonary (Airway and Lungs)
Hypoxia Sleep apnea Pneumonia

53 Hypoxia 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 oximetry Treat if O2 < 94% Oxygen by cannula or mask

54 Sleep Apnea Common 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.

55 Pneumonia Infection of the alveoi and small bronchioles
Alveoli fill with mucus and fluid Signs and symptoms: Looks ill Fever and chills Productive cough Chest pain with respiration Symptoms may be altered due to age No fever Poor cough

56 Respiratory 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?

57 Cardiovascular Dysrhythmias Myocardial Infarction
Congestive Heart Failure Dehydration Shock Abnormal Electrolytes (sodium, potassium) Anemia

58 Dysrhythmias Abnormal 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)

59 Myocardial Infarction
Signs and symptoms of myocardial infarction may be altered or absent. Silent MI with no chest pain Fatigue only symptom Confirm with 12 Lead EKG

60 Congestive Heart Failure
Early non-acute Congestive Heart Failure No pulmonary edema during day light hours Shortness of breath and dyspnea at night Holding extra body fluid in tissues Course rales/crackles in bases Jugular Vein distention Ankle edema

61 Shock --- Perfusion issues
Dehydration Drop in normal body water levels with aging Poor fluid intake (avoid going to the bathroom) No drop in blood pressure due to long term hypertension and hardening of arteries No tachycardia in response to fluid loss

62 Orthostatic Vital Signs
Check for dehydration with orthostatic vital signs Take BP and pulse when lying flat, sitting and standing Drop in BP and increase in pulse with position change = hypoperfusion = shock

63 Electrolyte Disorders
Long term use of diuretics what pull salts out of body Poor replacement of salts through body Look for dry mucus membranes Sodium (too high or too low) Potassium (too high or too low) No good way to check levels outside of lab tests in Emergency Department

64 Anemia – insufficient Red Blood Cells
Inadequate production of RBC Aplastic anemia Iron deficiency anemia Pernicious anemia Sickle cell anemia Increased RBC destruction Hemolytic anemia RBC loss – bleeding from somewhere

65 Cardiovascular 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?

66 Toxins Polypharmacy Overdose -- Accidental vs Intentional
Carbon Monoxide Poisoning Alcohol intoxication

67 Polypharmacy Older 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 drugs Polypharmacy = 30% of geriatric hospital admissions

68 OVerdose Common accidental overdoses: Tylenol® (Acetaminophen)
Potentially fatal due to liver failure Mixing over the counter and prescription pain medications Cold medications

69 Overdose Accidental 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)

70 Overdose Exposure to chemicals
Organophospate in “rose spray for aphids” Absorbs through skin Slow heart rate and low BP SLUDGE (salavation, lacrimatation, urination, diarrhea, gastric upset, emesis) Wash area of skin exposed

71 Carbon Monoxide Poisoning
Inhalation of gas that binds with hemoglobin Assessment/Associated Symptoms Headache Irritability Errors in judgment Confusion Vomiting Flu symptoms Pink color

72 Alcohol Intoxication Could this LOL (little old lady) be intoxicated??? Odor of alcohol on breath? Ethyl alcohol contained in elixirs and mouth wash Alcohol can cause a drop in blood sugar

73 Toxin 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?

74 Infections/Sepsis With 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.

75 Septicemia 90% fatal Results from presence of microorganisms or their toxic products in bloodstream -- Patients may present with: Hot, flushed appearance Tachycardia and tachypnea Hypotension Chills, cough

76 Infection 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?

77 Environmental Hypothermia Hyperthermia

78 Temperature 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?

79 Gastrointestinal/Genitourinary
Renal Failure GI bleeding Abdominal Aortic Aneurysm Malnourished

80 Renal Failure Elderly people are at greater risk for renal failure due to wear and tear to the kidney structures Risk is compounded by diabetes and hypertension.

81 Acute Renal Failure Assessment
Change in urine output Swelling in face, hands, feet, or torso Presence of heart palpitations or irregularity Changes in mental function

82 GI Bleeding (upper and Lower)
Deterioration of gastric linings with age Irritation of gastric linings due to use of over the counter pain medications such as Ibuprofen and Naproxen Sodium Blood in emesis or stools Black tarry stools Coffee ground emesis

83 May miss GI bleeding when taking vitamins with iron that can turn stools black
Assess for signs and symptoms of hypoperfusion – shock

84 Abdominal Aortic Aneurysm
Walls of the aorta weaken with age May leak before rupture Bleeding may be slow at first Look for signs and symptoms of shock “Pulsing mass ‘ may be difficult to find May complain of back pain more than abdominal pain .

85 Acute Abdomen Complaints of abdominal pain in older patients usually indicate a serious event. Nervous system response to pain is lessened. Complaint may be only weakness Consider gastrointestinal problems or abdominal aortic aneurysm.

86 Malnourishment 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?

87 Gastrointestinal/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 vomiting Do 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?

88 Review If doing this CE individually, please e-mail your answers to:
Use “September 2014 CE” in subject box. IDPH site code: E-1214 You will receive an confirmation. Print this confirmation for your records and document in your PREMSS CE record book.

89 Review List 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.


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