Principles of Patient Assessment in EMS

1. Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

2. Chapter 19 – Assessment Approach to The Elderly © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

3. Objectives • Discuss how anticipating the potential for deficits and modifying the approach to the patient will ease the assessment process for both patient and EMS provider. • Describe the physiological changes of aging that relate to the body senses including vision and hearing, taste, smell, and pain response. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

4. Objectives (continued) • Describe the physiological changes of aging that relate to the following body systems including immune, endocrine, GI/GU, renal, cardiovascular, respiratory, nervous, integumentary, musculoskeletal systems • Discuss the affects of aging as they relate to vital signs. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

5. Objectives (continued) • Explain why body temperature is an important vital sign in the late adult. • List the factors that lead to concern about the psychological status relating to aging. • Describe how the approach to obtaining a focused history from the late adult is different from that of a younger adult. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

6. Objectives (continued) • Describe how the approach to performing the physical exam on the late adult is different than that of a younger adult. • Describe why the assessment and management of the elderly patient includes evaluation of MS, physical functional status, emotional functional status and social functional status. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Objectives (continued) • List the common diseases found in the elderly and discuss specific factors and the signs and symptoms associated with each. • Discuss specific types of trauma that are more prevalent in the elderly populations and explain why traumatic injury is so devastating to the late adult population. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Introduction • The overall health status of the elderly patient is often difficult to determine. • Components to consider: • Medical and psychosocial • Functional problems • Daily living conditions © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. Introduction (continued) • Normal physiological changes that occur with aging makes assessment dynamic. • Hearing and vision loss contribute to difficulty in assessment. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Introduction (continued) • Anticipating the potential for deficits can help to modify your assessment approach. • Too many people asking too many questions too fast can overwhelm the patient. • Be prepared to slow things down. • Utilize family/caretakers to clarify or verify info after speaking with the patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Physiological Changes of Aging • Everyone ages at a different pace, but ultimately the aging process affects all body organs and systems. • It is important to consider these changes when performing an assessment on an elderly patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. The Senses • Hearing loss (presbycusis) – difficulty hearing whispered words and consonants. • Speak in a normal tone. Never shout. • Look at the patient’s face when speaking (lip reading). • Assess for hearing aides. Have the patient adjust them. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. The Senses (continued) • Kinesthetic (body position) sense – affects balance which contributes to falls. • Visual sense – decreased acuity, loss of accommodation and cataract opacification. • Contributes to falls and injuries • Let the patient wear glasses • Explain what you are doing • Pain response – decreases contributing to atypical and vague complaints to medical conditions or traumatic injury. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. The Senses (continued) • Taste and smell – decreased sensations can lead to loss of appetite. • Decreased sense of thirst is common and leads to a persistent state of mild, moderate or severe dehydration • Routinely ask about PO intake and recent changes, especially when a patient is taking diuretics © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. The Immune System • Loss of T-cell function effects the inflammatory response. • Increased susceptibility to infection. • The EMS providers must minimize the risk of cross contamination. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. The Endocrine System • Decreased insulin production leads to abnormal glucose metabolism. • Decreased Cortisol production (needed to cope with stresses on the body). • Decreased thyroid hormone predisposes to hypothyroidism. • Reproductive organs atrophy. • Pituitary or “master gland” decreases effectiveness resulting in generalized decrease in all endocrine function. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. The Renal System • Decreased blood flow and waste elimination. • 50% loss of nephrons – decreased excretion of fluid, salts, and waste products. • Reproductive organs atrophy. • Pituitary “master gland” - decreases effectiveness resulting in generalized decrease in all endocrine functions. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. The Cardiovascular System • Changes affect blood cells, blood vessels, and the heart. • Coronary artery disease predominates in the elderly. • Decreased cardiac output and decreased catecholamine affects rate response to stress and exercise. • Decreased blood volume. • Decreased production of red blood cells and platelets. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

19. Cardiovascular System (continued) • Low grade anemia is common. • Walls of blood vessels thicken causing increased peripheral vascular resistance. • Baroreceptors lose sensitivity and increase orthostatic changes. Posterior hypotension from inadequate compensatory mechanisms develops. • Myocardium is less elastic causing increased work load. Reserves become limited so tachycardia is not well tolerated. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

20. Cardiovascular System (continued) • Heart size can increase (cardiomegaly) due to disease which further increases the work load. • Conduction system develops fibrous tissue and loss of pacemaker cells leads to dysrhythmias. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

21. The Respiratory System • Changes occur in the mouth, nose, and lungs. • Tissue atrophy and loss of mucous membrane linings. • Decreased muscle mass and chest wall weakness. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

22. The Respiratory System • Loss of elasticity affects lung compliance, ventilation and gas exchange. • Ineffective cough reflex and decreased cilia contributes to increased risk of respiratory infections. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

23. The Nervous System • Loss of neurons and neurotransmitters. • Reflexes and reaction responses slow. • Sleep wake cycle is disturbed. • Brain atrophy increases the risk of brain injury. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

24. The Integumentary System • Skin thins and subcutaneous fat diminishes from extremities and redistributes to the hips and abdomen. • Loss of sebaceous glands and vascularity affects thermoregulation (increased risk of hypothermia). • Loss of elasticity causes sagging, wrinkles, and poor turgor. • Dry skin is common. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

25. The Musculoskeletal System • Decreased muscle mass and height. • > 70 yrs. Spine shrinks and extremities become disproportionately longer. • Abdominal muscles are thin making palpation of organs easier. • Swallowing becomes impaired (dysphagia). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

26. The Vital Signs • Changes vary depending upon patient’s physical and health status. • Pulses: • Distal pulses become more difficult to palpate • Ectopic beats are more common • Orthostatic changes occur easily with change of position. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

27. The Vital Signs (continued) • Respiratory Rate: • Gradual deterioration of pulmonary function • Even mild dyspnea is a significant finding • Normal ranges are the same as a younger adult © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

28. The Vital Signs (continued) • Blood Pressure: • A gradual rise in systolic pressure over the years is normal • Atrial HTC is currently the single greatest health problem in the U.S.A • Usually asymptomatic until severe complications (i.e. stroke) occur © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

29. The Vital Signs (continued) • Body Temperature: • Slightly lower temp may be noted due to impaired control mechanisms • Temp is an important VS in the elderly • Decline in thermoregulatory function impairs homeostasis • Modest elevations or subnormal are indications for concern, especially when associated with confusion, loss of appetite, or other behavioral changes • Temp changes may indicate pneumonia, UTI, and sepsis © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

30. Psychological Status • A decline in overall well being can occur from the effects of aging: • Increased health problems • Loss of self worth • Unproductive or unable to work • Increased financial burdens • Death and dying of spouse and friends • Loss of support system • Decreased independence • Increased alcohol or substance abuse • Depression © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

31. Focused History • Be prepared to spend more time obtaining a Hx. • When appropriate attempt to assess what the daily living activities consist of and how well the patient functions in the environment. • Note any new or recent changes. • Does the patient need help with daily living activities? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

32. The OPQRST History • O – Is this a new problem or preexisting one? • P – What was the patient doing at onset? Any trauma involved? • Q – What does the pain feel like and where is it located? (beware subtle signs!) • R – Any radiation/ Any attempted interventions and what were their effect? • S – compare baseline to serial assessments to see if it is improving. • T – When did the symptoms begin? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

33. The SAMPLE History • S – What are the associated symptoms? • A – Any allergies or sensitivity to meds? • M – Watch for polypharmacy. Include over-the-counter meds, herbals and home remedies. • P – Ask a family member and find out who the primary care / specialist physicians are. • L – Any changes in appetite or problems eating or drinking? • E – What events led up to the call for EMS? Is this related to a chronic condition or new? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

34. Physical Exam: Challenges • Patient often has concurrent illnesses. • Loss of pain sensation may obscure findings. • Patient often ears several layers of clothing. • Must be handled gently to avoid additional injury. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

35. Physical Exam: Challenges • Explaining steps and assuring modesty can take extra time. • Serious problems are often underestimated due to vague complaints. • Recognizing subtle clues is a key component. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

36. Medical Assessment • Make an introduction and begin the IA (MS-ABC). • Be respectful courteous, and ask permission prior to touching. • Explain the steps being taken. • Consider support services when appropriate. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

37. Psychological & Social Assessment • Psychological: • Consider MS and affect while obtaining a FH. • Note signs of healthy well being, loneliness or depression. • Consider support services. • Social: • Determine the patient’s support system. • Consider support services. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

38. Functional/Physical Limitation Assessment • Inspect the patient’s surroundings. • Does the patient appear to be able to perform daily living activities: • Eating • Bathing • Dressing • Toileting • Does the home need improvements to make the daily routine easier? • Can you help the patient get support services? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

39. Use of Diagnostic Tools • Obtain an ECG on any patient with: • An irregular pulse • Orthostatic changes (dizzy, weak) • Dyspnea (often cardiac related) • AMS • Typical and atypical chest pain • Obtain a glucose reading with suspected AMS. • Obtain a temperature reading with suspected AMS, loss of appetite or other behavioral changes. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

40. Common Diseases in the Elderly • Heart disease – signs/symptoms can be vague and misdiagnosed. • Subtle findings include: • AMS, fever, weakness or fatigue • Mild dyspnea, especially with excersion • Irregular heart beat/dysrhythmias • Epigastric, back or neck pain • More obvious findings include: • Severe dyspnea • Nausea and or vomiting • Dizziness or syncope • Heart burn indigestion • Diaphoresis, tingling and numbness © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

41. Hypertension • Defined as > 140/90, affects nearly 50 million in the U.S.A. • Prevention helps reduce risk of developing heart disease, but HTH is often asymptomatic. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

42. Pulmonary Disease • Emergencies usually associated with complications of COPD. • COPD patients are at increased risk for respiratory infections. • C/C is usually dyspnea, exertional dyspnea, orthopnea, or tachycardia. • Lung sounds can vary throughout the chest. • Respiratory emergencies are often complicated by concurrent disease processes such as CHF or pneumonia. • Getting an accurate Hx. Is key to making a working diagnosis. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

43. Pulmonary Disease (continued) • Chronic Bronchitis – Hx. of infections, coughing and smoking. • Emphysema – Hx. of smoking, clubbed digits, barrel chest, signs of right heart failure, cough, possible weight loss. • Pneumonia – Hx. of recent respiratory infection, coughing, fever, subnormal temp., unilateral adventitious or diminished breath sounds. • Pulmonary embolism – Hx. of heart failure, recent surgery, immobilization, or estrogen use. C/c progressive worsening dyspnea, pleuritic chest pain, leg pain, anxiety and no cough or fever. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

44. Diabetes • High prevalence in the elderly. • Physical/cognitive impairment makes this disease difficult to manage. • Increased prevalence of neuropathy causing an increased chance of infection and slower healing. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

45. Thyroid Disease • Thyroid hormones tell the body how fast to work and use energy. • Signs/symptoms are vague and are similar to many different conditions: • Non-acute confusion • Muscle aches and pains • Weakness and falling • Incontinence • Changes in appetite • Weight loss or gain © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

46. Alzheimer’s Disease • A progressive neurological condition that robs memory and intellect. The 4th leading cause of death in American adults. • Emergencies fall into 3 categories: • Behavioral – patient wandering around, uncooperative, acute anxiety, hostility or paranoia • Metabolic – dehydration, infection and drug toxicity • Psychiatric - depression © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

47. Parkinson’s Disease • A disease that damages nerve cells. • Average age of onset is 57. • Emergencies associated with falls, dementia, dysphagia, and drug toxicity. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

48. Cancer • More than 60% of cancer patients are age 65 and older. • Assessment is symptom based. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

49. Non-Acute Causes of Confusion • Dementia – gradual onset (months to years). • Delirium – mildly acute onset (hours to days). Most causes are reversible. • Depression – may cause impaired memory, inability to concentrate, and decreased cognitive functions. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

50. Trauma: Abuse and Falls • Abuse or neglect often underreported. Most common abusers are family. • Fear of increased abuse or being moved to a nursing home. • Major problem – falls are the 6th leading cause of death >65 years of age. • Common injuries include hip and upper limb fractures and TBIs. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.