physical distress: recognizing the signs

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Physical Distress:Recognizing the Signs

Presented by:

KEPRO SW PA Health Care Quality Unit(KEPRO HCQU)

March 2016 mlg

Disclaimer

Information or education provided by the HCQU is not intended to replace medical advice from the individual’s personal care physician, existing facility policy, or federal, state, and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those attending the training in its entirety. Attendees are responsible for submitting paperwork to

their respective agencies.

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Objectives

• Recognize signs of physical distress

• Identify situations that may lead to physical distress

• List appropriate actions which caregivers should take when an individual exhibits signs of physical distress

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Defining Distress

• Mental or physical suffering (Medical Dictionary for the Health Professions and Nursing, 2012)

• “Bodily dysfunction or discomfort caused by disease or injury;

• The condition of being in need of immediate assistance”(American Heritage® Dictionary of the English Language, Fifth Edition, 2011)

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Conditions That May Lead To Physical Distress• Illness

– Infections, gastrointestinal problems

• Injury– Cuts, broken bones, electrocution

• Seizures

• Medication Side Effects

• Restraints

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Areas to Observe

• Head, Face and Neck

• Chest

• Abdomen

• Extremities

• Generalized Clues

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Head, Face, and Neck

• Level of consciousness

• Color of lips and face

• Visible beating of the artery in the side of the neck (carotid artery)

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Head, Face, and Neck

• Nostrils

– Nasal flaring

• Mouth

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Chest

• Use of accessory muscles

• Sternal retractions

• Respiratory rate

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Abdomen

• Size of abdomen

• Softness of abdomen

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Extremities

• Color

• Temperature

• Shape

• Swelling

• Color of nail beds

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General Signs of Distress

• Sounds

• Bleeding

• Sweating

• Incontinence

• Change in Behavior

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Utilize Caution with Restraints

• Use approved techniques properly at all times

• Observe for signs of physical distress during the restraint

• Release the individual from the restraint if there are any signs or suspicions of physical distress observed.

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Helping an Individual in Physical Distress

• Call 911

• Basic First Aid

• Contact the individual’s physician

• CPR

• Remain calm and be confident

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GROUP ACTIVITY

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Scenario 1: Illness

Mildred ThomasA Case of Untimely Medical Attention

and a Sister’s Plea

Source: NYS Commission on Quality of Care

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Scenario 2: Injury

Charlie StevensA Study in the Delay of Timely Medical Care


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Scenario 3: Illness

Joseph FitzgeraldFailure to Seek Prompt

Medical Care has Tragic Consequences


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Related Training Topics

• Emergency Care: When to Seek

• Medical Care Facilities: Appropriate Use

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References

• Distress. (n.d.) Medical Dictionary for the Health Professions and Nursing. (2012). Retrieved February 9 2016 from http://medical-dictionary.thefreedictionary.com/distress

• Distress. (n.d.) American Heritage® Dictionary of the English Language, Fifth Edition. (2011). Retrieved February 9 2016 from http://www.thefreedictionary.com/distress

• Could This Happen in your Program? (Archive), New York State Commission on Quality of Care and Advocacy for Persons with Disabilities. Retrieved November 15, 2010 from http://cqc.ny.gov/advocacy/training-and-technical-assistance/could-this-happen%20archive

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To register for future trainings orfor more information on this or any other physical or behavioral

health topic, please visit

www.KEPRO.comSelect the ‘Client Websites’ box in the upper-right corner,

then select the ‘PA HCQU’ link.

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Please take a few moments to complete the test and evaluation forms for this training.

Thank you!

Test and Evaluation

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Physical Distress – Recognizing the Signs Injuries Resulting from the Use of Mechanical Restraints Page 2 Other Injuries Resulting from the Use of Restraints:

• Impairment of circulation to a body part below the application of a restraint may lead to severe tissue damage causing death of the tissues. Fingers and / or toes have been amputated because of this lack of blood flow. Permanent damage can occur to nerves and tendons when exposed to prolonged pressure from restraints. The formation of blood clots is also increased due to poor blood flow below the area that is restrained. These blood clots have the potential to travel to the heart, lung or brain, resulting in heart attack, respiratory distress or stroke.

• Elimination is effected by the use of restraints, restricting the individual’s ability to defecate or urinate. This can lead to constipation, bowel obstruction, urinary retention, bladder infections and even damage to the kidneys. Incontinence leads to skin breakdown and psychological distress.

• Nutritional status is adversely affected by the use of restraints. Dehydration is a danger, as well as electrolyte imbalance when the individual does not have free access to water and food.

• Immobility caused by restraint use can lead to pneumonia and skin breakdown.

• The incidence of aspiration, (the taking in of fluids) (vomit, saliva, liquids or solids) into the lungs is more prevalent with the use of restraints.

• Self-inflicted wounds may occur as a desperate attempt to free oneself from the restraint.

Psychological Harm:

• The U.S. General Accounting Office (GAO), in an October 1999 report on improper seclusion and restraints, validated the notion that” patients may be severely traumatized while being restrained, even if no physical injuries are sustained: "

• Citing a Massachusetts state task force on the topic, the GAO stated, “The use of restraints on patients who have been abused often results in their re-experiencing their traumas and contributes to a setback in the course of treatment.”

Sources: www.psych-health.com/restrnog.htm#partone www.ombudmhmr.state.mn.us

Rev.11.10/at,cjp 02.16/mlg

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TACONIC DEVELOPMENTAL DISABILITIES SERVICE OFFICE - EMERGENCY GUIDELINES PAGE 2

INCIDENT EMERGENCY GUIDELINE

Fall with severe head injury (fall on face, bleeding, change in level of consciousness)

Call Ambulance - Do NOT move - Keep warm

Fall, unable to get up on own and normally would be able to do so


Fall, limb deformity noted


Fall, gets up on own but complains of pain or can’t walk or use arms normally

Take to ER

Fainting

Call Ambulance

Shaking chill with or without fever

Take to ER

Fever less than 103 by rectum or 102 by mouth

Call Doctor’s Office

Fever over 103 by rectum or 102 by mouth.

Take to ER

Temperature is 95 or less rectally

Take to ER

Heart rate is less than 60 or greater than 120

Call Ambulance

New onset incontinence


Ingestion of wrong medications of potential poison

Call poison control (800-336-6997)

New rash


New onset seizure

Call Ambulance, Roll to side

Seizure lasting 5+ minutes

Call Ambulance, Roll to side

TACONIC DEVELOPMENTAL DISABILITIES SERVICE OFFICE - EMERGENCY GUIDELINES Page 3

INCIDENT EMERGENCY GUIDELINE

Increase in seizure numbers


Possible stroke

Call Ambulance

Sudden loss of vision

Call Doctor’s Office, take to ER if Doctor unavailable

Vomiting over 6 hours, not holding down small sips of liquids

Call Doctor’s Office, take to ER if Doctor unavailable

Repeated vomiting/diarrhea over 12 hours

Take to ER

Repeated vomiting/diarrhea less than 12 hours but lethargic - Any bloody vomit/diarrhea

Call Ambulance

Repeated vomiting/diarrhea less than 12 hours, but alert


Special thanks to Saul Moroff, M.D. Medical Review Board Member, Anna Timell, M.D. Medical Director, Taconic DDSO, and Rene Paluba R.N., Commission Investigator, for their assistance in developing this case study. Source: New York State Commission on Quality of Care and Advocacy of Persons with Disabilities, Could This Happen in your Program Series.

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PHYSICAL DISTRESS – RECOGNIZING THE SIGNS

CHARLIE STEVENS STORY On September 17, 41 year‐old Charlie Stevens walked upstairs to his room to get ready for bed. It was the last time he ever walked. About Mr. Stevens: Charlie Stevens was the product of a normal pregnancy, but a difficult delivery. As a child, he had some gross motor coordination problems, and when he entered school he was diagnosed as having mild mental retardation. Mr. Stevens lived at home with his parents for most of his life. But as they grew older, and Mr. Stevens began presenting some behavioral challenges, his parents sought a residential placement. Mr. Stevens was accepted into an eight‐bed group home in the town where he lived and moved there when he was in his late twenties. In the group home, Mr. Stevens was independent in most activities of daily living: he could make simple meals, do his laundry, tend to hygiene and grooming needs, and needed only verbal reminders to take his medications. As part of his day habilitation program, Mr. Stevens did volunteer work at a couple of local charitable organizations. His long‐term goal, which staffs at both the residence and day program were helping him towards, was competitive employment. Mr. Stevens communicated clearly and was described as being a very good self‐advocate. In addition to mild mental retardation, however, Mr. Stevens was diagnosed as having bipolar disorder that seriously impacted his daily life. During manic phases, Mr. Stevens was not overly energetic; but during depressed cycles, he would become extremely lethargic and communicate only minimally. During these phases, Mr. Stevens would refuse to participate in outings or routine household chores and activities. He would also refuse to get out of bed to attend day program. In addition to seeing a psychiatrist and taking medications for his psychiatric condition, Mr. Stevens had a behavior plan in place to address his reluctance to do things during his “down” cycles This entailed direct staff monitoring, verbal prompts and even physical assistance to help Mr. Stevens through each step of daily living activities, such as getting up in the morning, showering, dressing, and heading out for day program. If needed, the behavior plan allowed staff to physically escort or guide Mr. Stevens, one on each of his sides, out of his room and to the van to attend program. Day program staff was also made available to assist residence staff in this process if the need arose. Once at day program, during these “down” cycles Mr. Steven’s mood would brighten and he tended to get into the swing of things. Although Mr. Stevens did not appear to be in a “down” cycle proximate to September 17th, he was experiencing increasing tremors and Parkinsonian‐like symptoms. He had episodes of unsteadiness on his feet, difficulty in ambulating and brief periods of confusion. As a result, Mr. Stevens required increased staff supervision and assistance. He was also started on a course of neurological work‐ups and medication adjustments to determine the origin of these symptoms.

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The September 17th Incident At about 8:30 on September 17th, Mr. Stevens went to his bedroom to retire for the night. As he was unsteady on his feet and might need assistance going up the stairs and getting undressed, one of the two group home staff on duty accompanied him. While taking off his shirt in his room, Mr. Stevens fell to the floor, landing first on his buttocks, then falling onto his back. The staff member who had accompanied him and witnessed the fall immediately shouted downstairs for help. Her supervisor, who had heard the thud of the fall and claimed it shook the whole house, was already on his way upstairs to see what had happened. Together, they assessed Mr. Stevens, who was verbal and responsive. He claimed his back hurt. His vital signs were normal. There was no bleeding, no evidence of broken bones, and he could move his extremities. When asked, however, he either could not or would not get up off the floor, according to the staff. When the two staff lifted him, he offered no assistance and seemed unwilling or unable to plant his feet beneath him and bear weight. When placed on the bed in a sitting position, Mr. Stevens “flopped” down onto his back. He seemed limp. Staff changed him into his bedclothes and he continued to claim his back hurt. The supervisor telephoned the on‐call nurse and reported Mr. Steven’s fall, normal vital signs, and his not getting up off the floor, which the supervisor attributed to Mr. Steven’s behavioral difficulties. He did not report Mr. Steven’s claims of back pain. Nor did the nurse ask if there were any complaints of injury or pain. The nurse advised the supervisor to call back if Mr. Stevens would not get up or if his condition worsened. The next morning, the supervisor, who had worked overnight, and another staffer who had relieved the second staff person of the night before, attempted to get Mr. Stevens up and ready for day program. Although awake and alert, Mr. Stevens did not respond to requests that he get ready. He continued to complain of back pain. Believing that Mr. Stevens was exhibiting a behavioral issue, staff dressed him with some difficulty. Mr. Stevens didn’t actively resist or protest their efforts, he simply made no effort to assist. As he couldn’t or wouldn’t move from the bed, day program staff was called to assist in physically escorting Mr. Stevens to program. Again, he didn’t resist residence and day program staff’s efforts. But he didn’t help either. When they lifted him from bed to a sitting and then a standing position, he didn’t support his own weight. He felt like “dead weight” they said. Unable to perform the approved two‐person escort, given Mr. Steven’s size, weight and inability/unwillingness to assist by bearing some weight and walking, three staff carried him down the stairs in a more‐or‐less horizontal position, sitting him down occasionally to catch their breath. Once down the stairs and on level ground, Mr. Stevens was placed in a wheel chair, taken to the van and transported to program. In the process of getting Mr. Stevens off the van at day program and transferred to a wheel chair and then to an easy chair, he was dropped once. Day program staff was alerted to the fall of the prior night, but they were also informed that he might be having a behavioral episode related to his bipolar disorder. As the morning went on, though, they became concerned that more was at play. They had never seen him like this before. His color was pale; he had no pink in his lips. Although responsive to questions, he kept his eyes closed most of the time. He needed a pillow placed in his easy chair to keep him propped in an upright position; his hands sat in his lap and he seemed unable to move them more than a couple of inches.

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Even when he was served a cup of coffee, a daily treat, which he relished, he could not grasp the cup; when staff held the cup with a straw to his mouth, the coffee dribbled from his lips when he attempted to drink. Nursing and administrative staff was alerted. Initially, it was thought that he should be seen at the clinic, but as conversations ensued it was decided to call 911 for transport to an emergency room. Subsequent Events Mr. Stevens arrived in the emergency room of a local hospital on the afternoon of September 18th. The fall of the night before, as well as his complaints of back pain and his inability to ambulate, were noted. A CT of the head and x‐rays of the spine were negative. As he couldn’t walk, he was admitted with plans for additional neurological and psychiatric work‐ups. An MRI was ordered. The MRI revealed that Mr. Stevens had suffered a severe spinal cord injury with a ligature rupture, compression at the C5 ‐ 6 juncture and significant edema, resulting in quadriplegia. His respiratory function was also now compromised. On September 19th plans were made to transfer him to another hospital for surgery, though the odds of surgery significantly correcting the quadriplegia were bleak. He underwent surgery on September 20th. Following surgery, Mr. Stevens remained quadriplegic with only occasional slight movement of his feet and shoulders. Within days he developed pneumonia and other infections, which did not respond to antibiotics over the course of his hospitalization. He also began having seizures. Despite aggressive treatment, Mr. Stevens died in early November. Source: New York State Commission on Quality of Care and Advocacy of Persons with Disabilities, Could This Happen in your Program Series.

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physical distress: recognizing the signs

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