Curriculum Update: Patients With Special Challenges and Interventions for Patients with Chronic Care Needs

1. Curriculum Update: Patients With Special Challenges and Interventions for Patients with Chronic Care Needs Condell Medical Center EMS System August 2006 Site Code # 10-7200-E1206 Revised by: Sharon Hopkins, RN, BSN EMS Educator

2. Patients With Hearing Impairments • Deafness – partial or complete inability to hear • Conductive problem due to: • infection • injury • earwax • Sensorineural deafness due to: • congenital problem, birth injury • disease, tumor, viral infection • medication-induced • aging • prolonged exposure to loud noise

3. Patients With Special Challenges - Hearing Impairments • Recognizing patients with hearing loss • Hearing aids • Poor diction • Inability to respond to verbal communication in the absence of direct eye contact • Speaks with different syntax (speech pattern) • Use of sign language

4. Patients With Special Challenges - Hearing Impairment • Assessment/management accommodations • Provide pen/paper • Do not shout or exaggerate lip movement • Speak softly into their ear canal • Use pictures or demonstrate procedures • Notify hospital so interpreter is available

5. Patients With Special Challenges - Visual Impairment • Etiologies • Injury • Disease • Degeneration of eyeball, optic nerve or nerve pathways • Congenital • Infection (C.M.V.)

6. Patients with Special Challenges - Visual Impairment • Central vs peripheral loss • Patients with central loss of vision are usually aware of the condition • Patients with peripheral loss are more difficult to identify until it is well advanced Central loss Peripheral loss

7. Patients With Special Challenges - Visual Impairment • Assessment/management accommodations • Retrieve visual aids/glasses • Explain/demonstrate all procedures • Allow guide dog to accompany patient • Notify hospital of patient’s special needs • Carefully lead patient when ambulatory • patient holds your arm • call out obstructions, steps and turns ahead oftime

8. Etiologies of Speech Impairment • Language disorders • Stroke •Hearing loss • Head injury •Lack of stimulation • Brain tumor •Emotional disturbance • Delayed development • Articulation disorder • Damage to nerve pathways passing from brain to muscles in larynx, mouth, or lips • Delayed development from hearing problems; slow maturation of nervous system • Speech can be slurred, indistinct, slow, nasal

9. Etiologies of Speech Impairment • Voice production disorders • Disorder affecting closure of vocal cords • Hormonal or psychiatric disturbances • Severe hearing loss • Hoarseness, harshness, inappropriate pitch, abnormal nasal resonance • Fluency Disorders • Not well understood • Marked by repetition of single sounds or whole words • Stuttering

10. Recognizing Patients With Speech Impairment • Reluctance to verbally communicate • Inaudible or nondiscernable speech pattern • Language disorders (aphasia) • Limitations in speaking, listening, reading & writing • Slowness to understand speech • Slow growth in vocabulary/sentence structure • Common causes: blows to head, GSW, other traumatic brain injury, tumors

11. Utilizing Translation Line

12. Patients With Special Challenges -Obesity • Definition • body weight 20% over the average weight of people same size, gender, age • >58 million Americans are obese • 2nd leading cause of preventable death • Etiologies • Caloric intake exceeds calories burned • Low basal metabolic rate • Genetic predisposition

13. Obesity Risk Factors • Hypertension • Stroke • Heart disease • Diabetes • Some cancers • Kidney failure

14. Assessment/management Accommodations- Obesity • Appropriate sized equipment • May have extensive medical history • Additional assistance for lifting/moving • Recognize your own biases • Assessment techniques may need to be altered

15. Breathing Considerations in Obesity • Lungs 35% less compliant • Increased weight of the chest • Increased work of breathing • Hypoxemia common • O2 sats not reliable on finger tips (poor circulation) • Diaphragm higher

16. Airway Considerations in Obesity Control of airway challenging!!! • Short neck • Large powerful tongue • Distorted landmarks • Cricoid pressure helpful in stabilizing anatomy during intubation attempts • Positioning is critical • towels, blankets, pillows

17. Circulation Considerations in Obesity • Hypertension common • Alternate blood pressure cuff size • may need to use thigh cuff around upper arm • if difficulty fitting cuff around upper arm, place around forearm, stethoscope over radial artery • Prone to pulmonary emboli due to immobility

18. Transport Considerations in Obesity • Can be dangerous • Ensure ample personnel • Patient must fit through doorway • Patient may not tolerate supine position • May need to remove cot from ambulance for patient to fit • Know weight limitations of stretcher

19. Patients With Special Challenges - Spinal Cord Injuries • Conditions result from nerve damage in the brain and spinal cord • MVC, sports injury, fall, GSW, medical illness • Paraplegia • Weakness/paralysis of both legs • Quadriplegia • Paralysis of all four extremities and possibly the trunk

20. Assessment/Management Accommodations - Spinal Cord Injuries • Assistive devices may need to be transported with the patient • May have ostomies (trachea, bladder,colon) • May be ventilator dependent • May need to transport wheel chairs • Priapism in male patients - may be presenting as a medical emergency

21. Patients With Special Challenges - Mental Illness • Any form of psychiatric disorder • Psychoses – mental disorders where there is loss of contact with reality; patient may not be aware they have a disorder • schizophrenia, bipolar, organic brain disorder • Neuroses-related to upbringing and personality where person remains “in-touch” with reality; patients are aware of their illness • depression, phobias, obsessive/compulsive disorder

22. Assessment/Management Accommodations - Mental Illness • Solicit permission before beginning care • Gain rapport/trust but your safety is first • Don’t make promises you can’t keep • Don’t be afraid to ask about medications, mental illness history, ingestion of alcohol or non-prescription drugs • Evaluate for underlying medical illnesses • If presents as danger to self or others; use proper restraints; document use and distal circulation • If handcuffs, police in rig to ride with patient

23. Patients With Special Challenges - Down’s Syndrome • Chromosomal abnormality that causes mild to severe mental retardation • IQ varies from 30-80 • Eyes slope upward and at the outer corners • Folds of skin at side of nose that covers inner corners of the eyes • Small face and facial features • Large and protruding tongue • Flattening on back of the head • Hands that are short and broad

24. Assessment/Management Accommodations - Down’s Syndrome • Congenital heart, intestinal, hearing defects • Limited learning capability • Generally affectionate and friendly • Utilize patience with assessment • Explain procedures before beginning task

25. Patients With Special Challenge - Emotional Impairment • Impaired intellectual functioning that results in inability to cope with normal responsibilities of life • Neurasthenia - irritability, lack of concentration, worry, hypochondria • Anxiety neurosis - mild deviation of mind with unpleasant distressing emotion to imagined fear • Compulsion neurosis - recurrent & intrusive thought, feeling, idea, or sensation • Hysteria

26. Emotional or Mental Impairment • IQ • Mild impairment 55-70 • Moderate impairment 40-54 • Severe impairment 25-39 • Profound impairment < 25 • Extensive history taking needed to differentiate emotional issue vs medical issue • Utilize patience and extra time in history taking and while providing care • Remain supportive & calm

27. Etiologies Emotional/Mental Impairment • During pregnancy • Use of alcohol, drugs or tobacco • Illness/infection (toxoplasmosis, rubella, syphilis, HIV) • Genetic • Phenlketonuria (PKU)-single gene disorder caused by a defective enzyme • Chromosomal disorder (down syndrome) • Fragile X syndrome - single gene disorder on Y chromosome. Leading cause of mental retardation

28. Etiologies Emotionally/Mentally Impaired cont’d • Poverty/cultural deprivation • Malnutrition • Disease-producing conditions (lack of cleanliness) • Inadequate medical care • Environmental health hazards • Lack of stimulation

29. Patients With Special Challenges - Emotionally or Mentally Impaired • Assessment/management accommodations • Chronological age may not beconsistent with developmental age • May have numerous underlying medical problems • May show no psychological symptoms apart from slowness in mental tasks • Moderate to severe may have limited or absent speech, neurological impairments • Allow extra time for evaluation and patient responses

30. Patients With Special Challenges Due to Disease • Physical injury or disease may result in pathological conditions that require special assessment and management skills • arthritis - muscular dystrophy • cancer - myasthenia gravis • cerebral palsy - poliomyelitis • cystic fibrosis - spina bifida • head injury • multiple sclerosis

31. Patients With Special Challenges - Arthritis - • Inflammation of a joint, characterized by pain, stiffness, swelling and redness • Has many forms and varies in its effects • Osteoarthritis - results from cartilage loss and wear of joints (elderly) • Rheumatoid arthritis - autoimmune disorder that damages joints/surrounding tissue • Ask patient least painful method to assist in moving & touching them

32. Patients With Special Challenges - Cancer • Signs and symptoms • Pale, ashen skin • Loss of hair due to chemotherapy • VAD (venous access device) • Weakness • Transdermal skin patches for pain medication • Determine if under hospice care and DNR status • DNR must be valid State form to be honored by EMS in field • questions - contact medical control

33. Patients With Special Challenges - Cerebral Palsy • Non-progressive disorder of movement and posture due to a damaged area of brain that controls muscle tone • Most occur before birth • cerebral hypoxia, maternal infection • Damage to fetal brain in later stages of pregnancy, during birth, newborn or early childhood

34. Patients With Special Challenges • Types of Cerebral Palsy • Spastic – abnormal stiffness and difficulty with movement • Athetoid – involuntary & uncontrolled movements • Ataxic – disturbed sense of balance & depth perception • Mixed - some combination of the above in one person

35. Patients With Special Challenges - Cerebral Palsy • Signs and Symptoms • Unusual muscle tone noted during holding and feeding • 60% have mental retardation/ developmental delay • Many have high intelligence • Weakness or paralysis of extremities • Each case is unique to the degree of limitations

36. Patients With Special Challenges - Cystic Fibrosis • Inherited metabolic disease of the lung and digestive system • Childhood onset • Defective, recessive gene inherited from each parent (become carrier if gene inherited from only 1 parent) • Gland in lining of lung produces excessive amounts of thick mucous • Pancreas fails to produce enzymes required to break down fats and their absorption from the intestines

37. Patients with Special Challenges - Cystic Fibrosis • Signs and Symptoms • Patient predisposed to chronic lung infections • Pale, greasy looking, foul smelling stools • Persistent cough/breathlessness • Stunted growth • Sweat glands produce salty sweat • May be oxygen dependent, need of suctioning • May be a heart/lung transplant recipient

38. Patients With Special Challenges - Previous Head Injuries • Traumatic brain injury affects cognitive, physical and psychological skills • Physical appearance may be uncharacteristic or may be obvious

39. Patients With Special Challenges - Previous Head Injury • Signs and Symptoms • Speech and mobility may be affected • Short term memory loss • Cognitive deficit of language and communication • Physical deficit in balance, coordination, fine motor skills • Patients may use protective or helpful appliances (ie: helmet, braces)

40. Patients With Special Challenges - Multiple Sclerosis • Progressive/incurable autoimmune disease • Brain and spine myelin destroyed • May be inherited or viral component • Begins in early adulthood • Physical/emotional stress exacerbates severity

41. Patients With Special Challenges - Multiple Sclerosis • Signs and Symptoms • Fatigue, mood swings • Vertigo • Muscle weakness; extremities that feel heavy and weak • Spasticity; difficulty ambulating • Slurred speech • Blurred vision • Numbness, weakness, or pain in face • Midlife incontinence; frequent UTI’s

42. Patients With Special Challenges - Muscular Dystrophy • Inherited, incurable muscle disorder that results in a slow but progressive degeneration of muscle fibers • Life span generally not beyond teen years • Duchenne muscular dystrophy • Most common sex-linked cause • Recessive gene that only affects males • Diagnosed after age 3

43. Patients With Special Challenges - Muscular Dystrophy • Signs and Symptoms • Child that is slow to sit and walk • Unusual gait • Patient eventually unable to ambulate • Curvature of the spine • Muscles become bulky and replaced with fat • Immobility causes chronic lung diseases • Management & care includes respiratory support

44. Patient With Special Challenges - Myasthenia Gravis • Chronic autoimmune disorder of CNS • Weakness to skeletal (voluntary) muscles • Caused by defect in transmission of nerve impulses to muscles • Eye & eyelid •Throat • Face • Extremities • Chewing, talking, swallowing • Symptoms vary by type & severity • Dependent on precise timing of daily medication • Can live normal or near normal life

45. Myasthenia Gravis • Signs and symptoms • Women ages 20-30; men ages 70-80 • Drooping eyelid, double vision • Difficulty speaking, chewing & swallowing • Weakened respiratory muscles • Exacerbated by infection, medications and menstruation • Controlled with drug therapy to enhance transmission of nerveimpulses

46. Patients With Special Challenges - Poliomyelitis (polio) • Infectious disease caused by poliovirus hominis • Virus is spread through direct and indirect contact with infected feces and by airborne transmission • Salk & Sabin vaccines in 1950 have reduced incidences • In USA polio virus now injected and not oral form (virus shed thru GI system when given orally)

47. Patients With Special Challenges - Poliomyelitis • Signs and Symptoms • Paralysis of lower extremities • Unable to ambulate • Chronic respiratory diseases • Management & care • Needs support for ambulation • May need careful handling of extremities to avoid further injury • Assessment may take longer due to body disfigurement

48. Patients With Special Challenges - Spina Bifida • Congenital defect where part of vertebra fails to develop, leaving part of the spinal cord exposed • Ranges from minimal severity to severely disabled • Loss of sensation in all areas below defect • Associated abnormalities • Hydrocephalus with brain damage • Cerebral palsy • Mental retardation

49. Patients With Special Challenges • Financial Challenges • A patient’s ability to pay should never be a factor in obtaining emergency care • Federal laws mandate that quality, emergency health care be provided, regardless of the ability to pay

50. Patients With Financial Challenges • Issues patient deals with • Homelessness • Chronic illness with frequent hospitalizations • Lack of funds for purchase of routine medications • Poor personal hygiene • Poor nutritional status • Emaciation