Transcript Little old lady who is weary

LOL WIW
(LITTLE OLD
LADY WHO IS WEARY)
PRESENCE REGIONAL EMS SYSTEM
SEPTEMBER CONTINUING EDUCATION
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.
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!!
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?
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.
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
PHYSIOLOGICAL CHANGES WITH AGING
• Changes from aging can
• make assessment confusing.
• mask a real physiological problem
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
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)
Changes in the body systems of the elderly
PHYSIOLOGIC CHANGES
• Skin
• Susceptible to injury; longer healing time
• Senses
• Dulling of the senses
• Respiratory system
• Decreased ability to exchange gases
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
PHYSIOLOGIC CHANGES
• Musculoskeletal system
• Decrease in muscle mass and strength
• Gastrointestinal system
• Decrease in ability of body to digest food properly
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.
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
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
• 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?
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?
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.
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
FOCUSED HISTORY
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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.
• 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.
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.
COMMON COMPLAINTS
• Fatigue
• Fever
• Dyspnea
• Trauma
• Chest pain
• Falls
• Altered mental status
• Generalized pain
• Dizziness or weakness
• Nausea, vomiting, and
diarrhea
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?
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)
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Trauma
Infection
Psychosis
Stroke, Shock, Sepsis
OR
• Assess Head to Toe
• Assess by Body Systems
NEUROLOGICAL (HEAD AND
PSYCHOLOGICAL) POSSIBLE CAUSES
• Altered Mental State
• Abuse
• Stroke
• Alzheimer's
• Transient Ischemic Attack
• Depression
• Syncope
• Exhaustion
• Post Ictal
• Head Injury
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.
• Confusion is not normal!!!
• New onset confusion is a serious sign
of a medical emergency!!
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
Change in altered mental status can denote
serious underlying problems.
WHAT IS A STROKE?
• Disruption of blood flow to the brain
• Plaque
• Foreign debris
• Broken vessel
TRANSIENT ISCHEMIC ATTACK
• “One Free Spin”
• Looks like a stroke but, symptoms improve in 1-24
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
FAST STROKE (TIA) ASSESSMENT
• Modification of Cincinnati Pre-Hospital Stroke Screen
• Face
• Arm
• Speech
• Time of onset
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
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
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
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
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
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.
SEIZURES
• Generalized Seizures
• Post ictal: period of rest, sleep, or confusion
after a generalized seizure event.
SEIZURES VS SYNCOPE
Differentiating Between Syncope & Seizure
Bystanders frequently confuse syncope and
seizure.
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
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.
EXHAUSTION
• Normal fatigue
• Are you sick and tired of being sick and tired?
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.
ELDER ABUSE CAN COME IN SEVERAL
FORMS
Physical Abuse
Financial Abuse
Emotional Abuse
Isolation
Neglect
Medical care
Medications
Food
ASSESSMENT OF ELDER ABUSE
• Chronic pain
• Self-destructive behavior
• Eating and sleeping disorders
• Depression or a lack of energy
• Substance and/or sexual abuse
HOT LINE NUMBER FOR ELDER ABUSE
•In Illinois
•1-866-800-1409
NEUROLOGICAL/PSYCHOLOGICAL ASSESSMENT
QUESTIONS
• 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?
• 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?
PULMONARY (AIRWAY AND LUNGS)
• Hypoxia
• Sleep apnea
• Pneumonia
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
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.
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
RESPIRATORY ASSESSMENT QUESTIONS
• Are you having trouble breathing?
• Do you cough anything up?
• Do you feel short of breath?
• What color sputum are you
coughing up?
• Do family tell you that your snore at
night?
• Do you wake up tired?
• Do you have a cough?
• Do you feel like you have a fever?
• Does it hurt to breathe?
CARDIOVASCULAR
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Dysrhythmias
Myocardial Infarction
Congestive Heart Failure
Dehydration
Shock
Abnormal Electrolytes (sodium, potassium)
Anemia
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)
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
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
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
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
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
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
CARDIOVASCULAR ASSESSMENT QUESTIONS
• Does your heart race?
• Do your ankles swell?
• Do you feel like your heart is beating too
slow?
• Are you thirsty?
• 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?
• 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?
TOXINS
• Polypharmacy
• Overdose -- Accidental vs Intentional
• Carbon Monoxide Poisoning
• Alcohol intoxication
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
OVERDOSE
• Common accidental overdoses: Tylenol® (Acetaminophen)
• Potentially fatal due to liver failure
• Mixing over the counter and prescription pain medications
• Cold medications
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)
OVERDOSE
• Exposure to chemicals
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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
CARBON MONOXIDE POISONING
• Inhalation of gas that binds with hemoglobin
• Assessment/Associated Symptoms
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Headache
Irritability
Errors in judgment
Confusion
Vomiting
Flu symptoms
Pink color
ALCOHOL INTOXICATION
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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
TOXIN EXPOSURE ASSESSMENT QUESTIONS
• Have you been taking your medications the way
they are prescribed?
• Have you been exposed to any chemicals in the
last 24 hours? Cleaning, gardening?
• Do you have new mediations?
• Do you have a smoke detector/CO detector?
• Do you take over the counter medications in
addition to your prescriptions?
• Is anyone else in the house feeling weary?
• How much over the counter medication have
you taken?
• Do you drink alcohol regularly?
• Could you have taken too much medication?
• Have you been drinking alcohol?
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.
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
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?
ENVIRONMENTAL
• Hypothermia
• Hyperthermia
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?
GASTROINTESTINAL/GENITOURINARY
• Renal Failure
• GI bleeding
• Abdominal Aortic Aneurysm
• Malnourished
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.
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
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
• May miss GI bleeding when taking vitamins with iron that
can turn stools black
• Assess for signs and symptoms of
hypoperfusion – shock
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
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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.
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?
GASTROINTESTINAL/GENITOURINARY ASSESSMENT
QUESTIONS
• Have you had any problems going to the
bathroom?
• Can you pee?
• Have you been vomiting blood? Black?
• Does your urine smell bad?
• Have your stools had blood in them? Black
color?
• 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?
• What have you been eating?
• Is there a problem getting food?
• Is there a problem preparing food?
REVIEW
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If doing this CE individually, please e-mail your answers to:
[email protected]
Use “September 2014 CE” in subject box.
IDPH site code: 06-7100-E-1214
You will receive an e-mail confirmation. Print this
confirmation for your records and document in your
PREMSS CE record book.
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.