Principles of Patient Assessment in EMS. Assessment Approach to The Elderly.

Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

Assessment Approach to Assessment Approach to The Elderly The Elderly

IntroductionIntroduction The overall health status of the The overall health status of the

elderly patient is often difficult to elderly patient is often difficult to determine.determine.

Components to consider:Components to consider: Medical and psychosocialMedical and psychosocial Functional problemsFunctional problems Daily living conditionsDaily living conditions

Normal physiological changes that Normal physiological changes that occur with aging makes assessment occur with aging makes assessment dynamic.dynamic.

Hearing and vision loss contribute to Hearing and vision loss contribute to difficulty in assessment. difficulty in assessment.

Introduction (continued)Introduction (continued)

Introduction Introduction (continued)(continued) Anticipating the potential for deficits can Anticipating the potential for deficits can

help to modify your assessment help to modify your assessment approach.approach.

Too many people asking too many Too many people asking too many questions too fast can overwhelm the questions too fast can overwhelm the patient.patient.

Be prepared to slow things down.Be prepared to slow things down. Utilize family/caretakers to clarify or Utilize family/caretakers to clarify or

verify info after speaking with the patient. verify info after speaking with the patient.

Physiological Changes of Physiological Changes of AgingAging

Everyone ages at a different pace, Everyone ages at a different pace, but ultimately the aging process but ultimately the aging process affects all body organs and systems.affects all body organs and systems.

It is important to consider these It is important to consider these changes when performing an changes when performing an assessment on an elderly patient.assessment on an elderly patient.

© 2003 Delmar Learning, a Division of Thomson Learning, © 2003 Delmar Learning, a Division of Thomson Learning, IncInc. .

The SensesThe Senses Hearing loss (presbycusis) – difficulty Hearing loss (presbycusis) – difficulty

hearing whispered words and hearing whispered words and consonants.consonants.

Speak in a normal tone. Never Speak in a normal tone. Never shout.shout.

Look at the patient’s face when Look at the patient’s face when speaking (lip reading).speaking (lip reading).

Assess for hearing aides. Have the Assess for hearing aides. Have the patient adjust them.patient adjust them.


The Senses The Senses (continued)(continued) Kinesthetic (body position) sense – affects Kinesthetic (body position) sense – affects

balance which contributes to falls.balance which contributes to falls. Visual sense – decreased acuity, loss of Visual sense – decreased acuity, loss of

accommodation and cataract accommodation and cataract opacification.opacification. Contributes to falls and injuriesContributes to falls and injuries Let the patient wear glassesLet the patient wear glasses Explain what you are doingExplain what you are doing

Pain response – decreases contributing to Pain response – decreases contributing to atypical and vague complaints to medical atypical and vague complaints to medical conditions or traumatic injury.conditions or traumatic injury.

The Senses The Senses (continued)(continued) Taste and smell – decreased Taste and smell – decreased

sensations can lead to loss of sensations can lead to loss of appetite.appetite. Decreased sense of thirst is common Decreased sense of thirst is common

and leads to a persistent state of mild, and leads to a persistent state of mild, moderate or severe dehydrationmoderate or severe dehydration

Routinely ask about PO intake and Routinely ask about PO intake and recent changes, especially when a recent changes, especially when a patient is taking diureticspatient is taking diuretics


The Immune SystemThe Immune System Loss of T-cell function effects the Loss of T-cell function effects the

inflammatory response.inflammatory response. Increased susceptibility to infection.Increased susceptibility to infection. The EMS providers must minimize The EMS providers must minimize

the risk of cross contamination.the risk of cross contamination.


The Endocrine SystemThe Endocrine System Decreased insulin production leads to Decreased insulin production leads to

abnormal glucose metabolism.abnormal glucose metabolism. Decreased Cortisol production (needed Decreased Cortisol production (needed

to cope with stresses on the body).to cope with stresses on the body). Decreased thyroid hormone Decreased thyroid hormone

predisposes to hypothyroidism.predisposes to hypothyroidism. Reproductive organs atrophy.Reproductive organs atrophy. Pituitary or “master gland” decreases Pituitary or “master gland” decreases

effectiveness resulting in generalized effectiveness resulting in generalized decrease in all endocrine function.decrease in all endocrine function.


The Renal SystemThe Renal System Decreased blood flow and waste Decreased blood flow and waste

elimination.elimination. 50% loss of nephrons – decreased 50% loss of nephrons – decreased

excretion of fluid, salts, and waste excretion of fluid, salts, and waste products.products.

Reproductive organs atrophy.Reproductive organs atrophy. Pituitary “master gland” - decreases Pituitary “master gland” - decreases

effectiveness resulting in generalized effectiveness resulting in generalized decrease in all endocrine functions.decrease in all endocrine functions.


The Cardiovascular SystemThe Cardiovascular System Changes affect blood cells, blood Changes affect blood cells, blood

vessels, and the heart.vessels, and the heart. Coronary artery disease Coronary artery disease

predominates in the elderly.predominates in the elderly. Decreased cardiac output and Decreased cardiac output and

decreased catecholamine affects rate decreased catecholamine affects rate response to stress and exercise.response to stress and exercise.

Decreased blood volume.Decreased blood volume. Decreased production of red blood Decreased production of red blood

cells and platelets.cells and platelets.© 2003 Delmar Learning, a Division of Thomson Learning, © 2003 Delmar Learning, a Division of Thomson Learning,

IncInc. .

Cardiovascular System Cardiovascular System (continued)(continued)

Low grade anemia is common.Low grade anemia is common. Walls of blood vessels thicken causing Walls of blood vessels thicken causing

increased peripheral vascular resistance.increased peripheral vascular resistance. Baroreceptors lose sensitivity and Baroreceptors lose sensitivity and

increase orthostatic changes. Posterior increase orthostatic changes. Posterior hypotension from inadequate hypotension from inadequate compensatory mechanisms develops.compensatory mechanisms develops.

Myocardium is less elastic causing Myocardium is less elastic causing increased work load. Reserves become increased work load. Reserves become limited so tachycardia is not well limited so tachycardia is not well tolerated.tolerated.


Heart size can increase Heart size can increase (cardiomegaly) due to disease (cardiomegaly) due to disease which further increases the work which further increases the work load.load.

Conduction system develops Conduction system develops fibrous tissue and loss of fibrous tissue and loss of pacemaker cells leads to pacemaker cells leads to dysrhythmias.dysrhythmias.

Cardiovascular System Cardiovascular System (continued)(continued)


The Respiratory SystemThe Respiratory System Changes occur in the mouth, nose, Changes occur in the mouth, nose,

and lungs.and lungs. Tissue atrophy and loss of mucous Tissue atrophy and loss of mucous

membrane linings.membrane linings. Decreased muscle mass and chest Decreased muscle mass and chest

wall weakness.wall weakness.


Loss of elasticity affects lung Loss of elasticity affects lung compliance, ventilation and gas compliance, ventilation and gas exchange.exchange.

Ineffective cough reflex and Ineffective cough reflex and decreased cilia contributes to decreased cilia contributes to increased risk of respiratory increased risk of respiratory infections.infections.

The Respiratory SystemThe Respiratory System


The Nervous SystemThe Nervous System Loss of neurons and Loss of neurons and

neurotransmitters.neurotransmitters. Reflexes and reaction responses Reflexes and reaction responses

slow.slow. Sleep wake cycle is disturbed.Sleep wake cycle is disturbed. Brain atrophy increases the risk of Brain atrophy increases the risk of

brain injury.brain injury.


The Integumentary SystemThe Integumentary System Skin thins and subcutaneous fat Skin thins and subcutaneous fat

diminishes from extremities and diminishes from extremities and redistributes to the hips and abdomen.redistributes to the hips and abdomen.

Loss of sebaceous glands and Loss of sebaceous glands and vascularity affects thermoregulation vascularity affects thermoregulation (increased risk of hypothermia).(increased risk of hypothermia).

Loss of elasticity causes sagging, Loss of elasticity causes sagging, wrinkles, and poor turgor.wrinkles, and poor turgor.

Dry skin is common.Dry skin is common.


The Musculoskeletal SystemThe Musculoskeletal System Decreased muscle mass and height.Decreased muscle mass and height. > 70 yrs. Spine shrinks and > 70 yrs. Spine shrinks and

extremities become extremities become disproportionately longer.disproportionately longer.

Abdominal muscles are thin making Abdominal muscles are thin making palpation of organs easier.palpation of organs easier.

Swallowing becomes impaired Swallowing becomes impaired (dysphagia).(dysphagia).


The Vital SignsThe Vital Signs Changes vary depending upon Changes vary depending upon

patient’s physical and health status.patient’s physical and health status. Pulses:Pulses:

Distal pulses become more difficult Distal pulses become more difficult to palpateto palpate

Ectopic beats are more commonEctopic beats are more common Orthostatic changes occur easily with Orthostatic changes occur easily with

change of position.change of position.


Respiratory Rate:Respiratory Rate: Gradual deterioration of pulmonary Gradual deterioration of pulmonary

functionfunction Even mild dyspnea is a significant Even mild dyspnea is a significant

findingfinding Normal ranges are the same as a Normal ranges are the same as a

younger adultyounger adult

The Vital Signs (continued)The Vital Signs (continued)


The Vital Signs The Vital Signs (continued)(continued) Blood Pressure:Blood Pressure:

A gradual rise in systolic pressure over A gradual rise in systolic pressure over the years is normalthe years is normal

Atrial HTC is currently the single Atrial HTC is currently the single greatest health problem in the U.S.Agreatest health problem in the U.S.A

Usually asymptomatic until severe Usually asymptomatic until severe complications (i.e. stroke) occurcomplications (i.e. stroke) occur


Body Temperature:Body Temperature: Slightly lower temp may be noted due to Slightly lower temp may be noted due to

impaired control mechanismsimpaired control mechanisms Temp is an important VS in the elderlyTemp is an important VS in the elderly Decline in thermoregulatory function impairs Decline in thermoregulatory function impairs

homeostasishomeostasis Modest elevations or subnormal are indications Modest elevations or subnormal are indications

for concern, especially when associated with for concern, especially when associated with confusion, loss of appetite, or other behavioral confusion, loss of appetite, or other behavioral changeschanges

Temp changes may indicate pneumonia, UTI, Temp changes may indicate pneumonia, UTI, and sepsisand sepsis

The Vital Signs (continued)The Vital Signs (continued)


Psychological StatusPsychological Status A decline in overall well being can occur A decline in overall well being can occur

from the effects of aging:from the effects of aging: Increased health problemsIncreased health problems Loss of self worthLoss of self worth Unproductive or unable to workUnproductive or unable to work Increased financial burdensIncreased financial burdens Death and dying of spouse and friendsDeath and dying of spouse and friends Loss of support systemLoss of support system Decreased independenceDecreased independence Increased alcohol or substance abuseIncreased alcohol or substance abuse DepressionDepression


Focused HistoryFocused History

Be prepared to spend more time Be prepared to spend more time obtaining a Hx.obtaining a Hx.

When appropriate attempt to assess When appropriate attempt to assess what the daily living activities consist what the daily living activities consist of and how well the patient functions of and how well the patient functions in the environment.in the environment.

Note any new or recent changes.Note any new or recent changes. Does the patient need help with daily Does the patient need help with daily

living activities?living activities?© 2003 Delmar Learning, a Division of Thomson Learning, © 2003 Delmar Learning, a Division of Thomson Learning,

IncInc. .

The OPQRST HistoryThe OPQRST History O – Is this a new problem or preexisting O – Is this a new problem or preexisting

one?one? P – What was the patient doing at onset? P – What was the patient doing at onset?

Any trauma involved?Any trauma involved? Q – What does the pain feel like and where Q – What does the pain feel like and where

is it located? (beware subtle signs!)is it located? (beware subtle signs!) R – Any radiation/ Any attempted R – Any radiation/ Any attempted

interventions and what were their effect?interventions and what were their effect? S – compare baseline to serial assessments S – compare baseline to serial assessments

to see if it is improving.to see if it is improving. T – When did the symptoms begin?T – When did the symptoms begin?


The SAMPLE HistoryThe SAMPLE History S – What are the associated symptoms?S – What are the associated symptoms? A – Any allergies or sensitivity to meds?A – Any allergies or sensitivity to meds? M – Watch for polypharmacy. Include over-M – Watch for polypharmacy. Include over-

the-counter meds, herbals and home the-counter meds, herbals and home remedies.remedies.

P – Ask a family member and find out who P – Ask a family member and find out who the primary care / specialist physicians are.the primary care / specialist physicians are.

L – Any changes in appetite or problems L – Any changes in appetite or problems eating or drinking?eating or drinking?

E – What events led up to the call for EMS? E – What events led up to the call for EMS? Is this related to a chronic condition or new?Is this related to a chronic condition or new?


Physical Exam: ChallengesPhysical Exam: Challenges

Patient often has concurrent Patient often has concurrent illnesses.illnesses.

Loss of pain sensation may obscure Loss of pain sensation may obscure findings.findings.

Patient often ears several layers of Patient often ears several layers of clothing.clothing.

Must be handled gently to avoid Must be handled gently to avoid additional injury.additional injury.


Explaining steps and assuring Explaining steps and assuring modesty can take extra time.modesty can take extra time.

Serious problems are often Serious problems are often underestimated due to vague underestimated due to vague complaints.complaints.

Recognizing subtle clues is a key Recognizing subtle clues is a key component.component.

Physical Exam: ChallengesPhysical Exam: Challenges


Medical AssessmentMedical Assessment

Make an introduction and begin the Make an introduction and begin the IA (MS-ABC).IA (MS-ABC).

Be respectful courteous, and ask Be respectful courteous, and ask permission prior to touching.permission prior to touching.

Explain the steps being taken.Explain the steps being taken. Consider support services when Consider support services when

appropriate.appropriate.


Psychological & Social AssessmentPsychological & Social Assessment

Psychological:Psychological: Consider MS and affect while obtaining a Consider MS and affect while obtaining a

FH.FH. Note signs of healthy well being, Note signs of healthy well being,

loneliness or depression.loneliness or depression. Consider support services.Consider support services.

Social:Social: Determine the patient’s support system.Determine the patient’s support system. Consider support services.Consider support services.


Functional/Physical Limitation Functional/Physical Limitation AssessmentAssessment

Inspect the patient’s surroundings.Inspect the patient’s surroundings. Does the patient appear to be able to Does the patient appear to be able to

perform daily living activities:perform daily living activities: EatingEating BathingBathing DressingDressing ToiletingToileting

Does the home need improvements to Does the home need improvements to make the daily routine easier?make the daily routine easier?

Can you help the patient get support Can you help the patient get support services?services?


Use of Diagnostic ToolsUse of Diagnostic Tools

Obtain an ECG on any patient with:Obtain an ECG on any patient with: An irregular pulseAn irregular pulse Orthostatic changes (dizzy, weak)Orthostatic changes (dizzy, weak) Dyspnea (often cardiac related)Dyspnea (often cardiac related) AMSAMS Typical and atypical chest painTypical and atypical chest pain

Obtain a glucose reading with suspected Obtain a glucose reading with suspected AMS.AMS.

Obtain a temperature reading with Obtain a temperature reading with suspected AMS, loss of appetite or other suspected AMS, loss of appetite or other behavioral changes.behavioral changes.


Common Diseases in the ElderlyCommon Diseases in the Elderly Heart disease – signs/symptoms can be Heart disease – signs/symptoms can be

vague and misdiagnosed.vague and misdiagnosed. Subtle findings include:Subtle findings include:

AMS, fever, weakness or fatigueAMS, fever, weakness or fatigue Mild dyspnea, especially with excersionMild dyspnea, especially with excersion Irregular heart beat/dysrhythmiasIrregular heart beat/dysrhythmias Epigastric, back or neck painEpigastric, back or neck pain

More obvious findings include:More obvious findings include: Severe dyspneaSevere dyspnea Nausea and or vomitingNausea and or vomiting Dizziness or syncopeDizziness or syncope Heart burn indigestionHeart burn indigestion Diaphoresis, tingling and numbnessDiaphoresis, tingling and numbness


HypertensionHypertension

Defined as > 140/90, affects nearly Defined as > 140/90, affects nearly 50 million in the U.S.A.50 million in the U.S.A.

Prevention helps reduce risk of Prevention helps reduce risk of developing heart disease, but HTH is developing heart disease, but HTH is often asymptomatic.often asymptomatic.


Pulmonary DiseasePulmonary Disease Emergencies usually associated with Emergencies usually associated with

complications of COPD.complications of COPD. COPD patients are at increased risk for COPD patients are at increased risk for

respiratory infections.respiratory infections. C/C is usually dyspnea, exertional C/C is usually dyspnea, exertional

dyspnea, orthopnea, or tachycardia.dyspnea, orthopnea, or tachycardia. Lung sounds can vary throughout the Lung sounds can vary throughout the

chest.chest. Respiratory emergencies are often Respiratory emergencies are often

complicated by concurrent disease complicated by concurrent disease processes such as CHF or pneumonia.processes such as CHF or pneumonia.

Getting an accurate Hx. Is key to making a Getting an accurate Hx. Is key to making a working diagnosis.working diagnosis.


Pulmonary Disease Pulmonary Disease (continued)(continued) Chronic Bronchitis – Hx. of infections, Chronic Bronchitis – Hx. of infections,

coughing and smoking.coughing and smoking. Emphysema – Hx. of smoking, clubbed Emphysema – Hx. of smoking, clubbed

digits, barrel chest, signs of right heart digits, barrel chest, signs of right heart failure, cough, possible weight loss.failure, cough, possible weight loss.

Pneumonia – Hx. of recent respiratory Pneumonia – Hx. of recent respiratory infection, coughing, fever, subnormal infection, coughing, fever, subnormal temp., unilateral adventitious or temp., unilateral adventitious or diminished breath sounds.diminished breath sounds.

Pulmonary embolism – Hx. of heart failure, Pulmonary embolism – Hx. of heart failure, recent surgery, immobilization, or recent surgery, immobilization, or estrogen use. C/c progressive worsening estrogen use. C/c progressive worsening dyspnea, pleuritic chest pain, leg pain, dyspnea, pleuritic chest pain, leg pain, anxiety and no cough or fever.anxiety and no cough or fever.


DiabetesDiabetes

High prevalence in the elderly.High prevalence in the elderly. Physical/cognitive impairment makes Physical/cognitive impairment makes

this disease difficult to manage.this disease difficult to manage. Increased prevalence of neuropathy Increased prevalence of neuropathy

causing an increased chance of causing an increased chance of infection and slower healing.infection and slower healing.


Thyroid DiseaseThyroid Disease Thyroid hormones tell the body how Thyroid hormones tell the body how

fast to work and use energy.fast to work and use energy. Signs/symptoms are vague and are Signs/symptoms are vague and are

similar to many different conditions:similar to many different conditions: Non-acute confusionNon-acute confusion Muscle aches and painsMuscle aches and pains Weakness and fallingWeakness and falling IncontinenceIncontinence Changes in appetiteChanges in appetite Weight loss or gainWeight loss or gain


Alzheimer’s DiseaseAlzheimer’s Disease A progressive neurological condition A progressive neurological condition

that robs memory and intellect. The that robs memory and intellect. The 44thth leading cause of death in leading cause of death in American adults.American adults.

Emergencies fall into 3 categories:Emergencies fall into 3 categories: Behavioral – patient wandering around, Behavioral – patient wandering around,

uncooperative, acute anxiety, hostility uncooperative, acute anxiety, hostility or paranoiaor paranoia

Metabolic – dehydration, infection and Metabolic – dehydration, infection and drug toxicitydrug toxicity

Psychiatric - depressionPsychiatric - depression© 2003 Delmar Learning, a Division of Thomson Learning, © 2003 Delmar Learning, a Division of Thomson Learning,

IncInc. .

Parkinson’s DiseaseParkinson’s Disease

A disease that damages nerve cells.A disease that damages nerve cells. Average age of onset is 57.Average age of onset is 57. Emergencies associated with falls, Emergencies associated with falls,

dementia, dysphagia, and drug dementia, dysphagia, and drug toxicity.toxicity.


CancerCancer

More than 60% of cancer patients More than 60% of cancer patients are age 65 and older.are age 65 and older.

Assessment is symptom based.Assessment is symptom based.


Non-Acute Causes of ConfusionNon-Acute Causes of Confusion

Dementia – gradual onset (months to Dementia – gradual onset (months to years).years).

Delirium – mildly acute onset (hours Delirium – mildly acute onset (hours to days). Most causes are reversible.to days). Most causes are reversible.

Depression – may cause impaired Depression – may cause impaired memory, inability to concentrate, memory, inability to concentrate, and decreased cognitive functions.and decreased cognitive functions.


Trauma: Abuse and FallsTrauma: Abuse and Falls

Abuse or neglect often underreported. Abuse or neglect often underreported. Most common abusers are family.Most common abusers are family.

Fear of increased abuse or being Fear of increased abuse or being moved to a nursing home.moved to a nursing home.

Major problem – falls are the 6Major problem – falls are the 6thth leading cause of death >65 years of leading cause of death >65 years of age.age.

Common injuries include hip and Common injuries include hip and upper limb fractures and TBIs.upper limb fractures and TBIs.


Trauma: Hip / FemurTrauma: Hip / Femur

Associated with high mortality rates Associated with high mortality rates in the first year following injury.in the first year following injury.

Decreased quality of life.Decreased quality of life. Complications from surgery and Complications from surgery and

lengthy immobilization.lengthy immobilization.


Trauma: TBI & BurnsTrauma: TBI & Burns

TBI:TBI: Often result in poor outcomeOften result in poor outcome Increased risk of bleeding and swellingIncreased risk of bleeding and swelling

Burns:Burns: Often result in poor outcome due to skin Often result in poor outcome due to skin

changes, decreased immune response, changes, decreased immune response, and preexisting illnessesand preexisting illnesses


ConclusionConclusion

Assessment & management includes Assessment & management includes evaluation of MS, physical functional evaluation of MS, physical functional status, emotional status, and social status, emotional status, and social functional status.functional status.

EMS providers get to see the home EMS providers get to see the home environment, and can relay that info environment, and can relay that info to help complete an integral part of to help complete an integral part of the total health assessment.the total health assessment.


EMS providers rarely have time to EMS providers rarely have time to complete all 4 components.complete all 4 components.

Be prepared to spend more time Be prepared to spend more time gathering a Hx. and performing a PE.gathering a Hx. and performing a PE.

Helping a patient get the appropriate Helping a patient get the appropriate support services can make a support services can make a significant difference in quality of life. significant difference in quality of life.

ConclusionConclusion

Principles of Patient Assessment in EMS. Assessment Approach to The Elderly.

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