ECRN Packet: Culturally Diverse Patients Geriatric Population Medications for Home Use

1. ECRN Packet:Culturally Diverse PatientsGeriatric PopulationMedications for Home Use Condell Medical Center EMS System 2006 Site Code #10-7214-E-1206 Revised by Sharon Hopkins, RN, BSN EMS Educator

2. Objectives Upon successful completion of this module, the ECRN should be able to: • understand the sensitivity required when caring for a culturally diverse patient population. • describe the unique assessment and care necessary for the geriatric population • describe common medications taken by the population and potential impacts with clinical presentations

3. Culturally Diverse Patients • Differences of any kind: race, class, religion, gender, sexual preference, personal habitat, physical ability • Good healthcare depends on sensitivity toward these differences • Every patient is unique • Westernized medicine is not accepted by all

4. Culturally Diverse Patients • Key points • Individual is the “foreground”, culture is the “background” • Not all people identify with their ethnic cultural background • Respect the patient’s beliefs • Every patient needs to be treated equally • Do not force someone to have an intervention that is against their personal beliefs

5. Culturally Diverse Patients • Respect the integrity of cultural beliefs • Patients may not share your explanation of causes of ill health and not accept conventional treatments • Recognize your personal cultural assumptions, prejudices and belief systems. • Avoid letting your prejudices interfere with patient care

6. Patient Rights • Patients have the right to self-determination • If the patient is of legal age (18 or older, not emancipated), the patient has the right to refuse any care or treatment offered • Document what has been refused and why • The patient, or person authorized to consent, must sign for themselves • spouses, grandparents, older siblings, police officers cannot sign a refusal • if telephone permission is taken, witness by 2 persons, and add the name of the person supplying permission

7. Groups By Region • Many groups overlap regions • Older population usually refer to themselves by their ethnic region (ie: Chinese, Mexican) • Younger population usually refer to themselves by racial terms (ie: Asian, Latino) • Cannot always judge the ethnicity based on appearances - ask the patient if you need clarification

8. Culturally Diverse Patients • Locale of practice • get to know the predominate cultures of your area • the more you understand the culture, the more effective a practitioner you can be • know resources available in your hospital/community

9. Culturally Diverse Patients • Language barriers • your assessment and accuracy of interpretation will be hindered when a language barrier is present • if an interpreter is used, document their name and relationship • in some cultures, use of children is insulting to adults and seen as too much responsibility placed on the child • language lines are available - use them when gathering/sharing medically pertinent information

10. Culturally Diverse Patients And Body Language • Very important especially when a language barrier exists • Usually at a subconscious level • Components of body language • eye contact • facial expressions • proximity • posture • gestures

11. Body Language - Eye Contact • Can play a key role in establishing rapport • Failure to make eye contact can be a sign of dishonesty • Making eye contact can be a sign of disrespect in some cultures (Chinese)

12. Body Language - Facial Expressions • One of the most obvious forms of body language • Can convey mood, attitude, understanding, confusion, other emotions • Smiles are usually universally understood • Smiling and winking can have different connotations from a friendly gesture to flirting to disrespect (culture dependent)

13. Body Language - Proximity • Acceptability varies widely culture to culture • In the United States, twice the arm length is a comfortable social distance - 4-12 feet • Personal space is 1.5 - 4 feet • Different messages are interpreted when standing above, at, or below eye level • above eye level shows authority, can be intimidating • at eye level indicates equality • below eye level shows willingness to let patient have some control over the situation

14. Body Language - Posture • Range of attitudes conveyed from interest, respect, subordination, disrespect • Can replace or accompany verbal communication • Some cultures it is impolite to show the bottom of the shoe because it is dirty; they will not sit with a foot crossed & resting on opposite knee

15. Culturally Diverse Patients - Financially Challenged • May refuse health care due to its costs • We need to be an advocate for these people and make sure they are offered initial medical screening • Know your community and county resources to offer to this group of people • As a reminder, use your own resources wisely

16. Culturally Diverse Patients - Financially Challenged • Signs of impairment • homelessness • chronic illness with frequent hospitalizations • poor personal hygiene • self-employment

17. Resources for Referral • PADS - public access to provide shelter • provide meals and shelter October 1 - April 30 • open 7 pm - 7 am • goals - • connect person with resources to be able to leave the street • commit to own effort for health and recovery • to gain personal and economic self-sufficiency with safe, affordable permanent housing • HealthReach Clinic - medical screening • 847-360-8800 (Waukegan)

18. Resources for Referral • Catholic Charities • to help families & individuals overcome tragedy, poverty, other life challenges • Lake County • adult agency 847-377-4504 • juvenile agency 847-377-7800 • Salvation Army 847-336-1800 • Connection Crisis & Referral Hotline 847-689-1080 • Department Chaplain • Hospital Social Worker

19. Geriatrics

20. Challenges in the Geriatric Population • Fear of losing autonomy/independence • mobility - walking and by car • want to continue to live on own • Patient fears financial burden of hospitalization • Patient is embarrassed by burden they become to family and friends • Multiple disease processes affecting health • Difficulty in communicating pain and fears

21. Challenges in Dealing With the Geriatric Population • Patient fatigues easily • Many layers of clothing hamper detailed examination • Need for modesty and privacy • May minimize their symptoms • fear that they may be hospitalized, illness will cost money they don’t have, illness may cause nursing home or alternate living arrangements with loss of independence

22. Challenges in theGeriatric Population • Often suffer from concurrent illnesses • Chronic problems make assessment of acute problems difficult • Aging affects response to illness/injury • Social/emotional factors have great impact on health • Depression & isolation - highest suicide rates in people over 65

23. Sensory Related Changes • Vision • cataracts cause blurring of vision; unable to distinguish between blue & purple • if cataracts opaque (cloudy), may not see pupillary response with a penlight • be in front of person & make touch contact with the patient before beginning to speak • Hearing • decreased hearing • diminished sense of balance • speak slowly and distinctly; check for hearing aids; write notes if necessary

24. Taste & smell • altered (decreased sensitivity) • creates decreased appetite which causes poor nutritional condition • Touch • neuropathies cause decreased sensitivity to tactile senses • increased risk of injury without patient’s awareness (ie:burns from heating pads; sores on feet becoming infected) • Pain • lowered sensitivity - smaller amounts of pain medication are necessary

25. Communicating with the Geriatric Population • Make eye contact before speaking • Always identify yourself • Position yourself at the patient’s eye level • Locate hearing aid, eyeglasses, dentures • Turn on lights, turn off TV to minimize distractions • Use surname (Mr., Mrs., Ms.) until permission given to address patient otherwise • Be patient and gentle - give time for the patient to respond to your questions

26. Physiological Changes Affecting Mobility • Diminished vision • Loss of exercise tolerance • Diminished breathing capacity - become short of breath quicker and lose energy to complete tasks • Slowed psychomotor skills - losing independence • Decreased reflex time to prevent falls - more prone to injury

27. Mobility in Geriatrics • Bone loss affects mobility • Osteopenia - less than the normal amount of bone • Osteoporosis - bone mass so reduced that the skeleton loses its integrity and becomes unable to perform it’s supportive function • Loss of bone strength and size • Loss of flexibility • Vulnerable areas in women • spine, wrist, hip, collarbone, upper arm, leg, pelvis • Treatment - meds, weight bearing exercises like walking and lifting weights

28. Cardiovascular Changes in Geriatrics • Left ventricle thickens and enlarges (hypertrophy) decreasing compliance • Decreased responsiveness to catecholamine stimulation • Diminished ability to raise the heart rate in response to stress • Decreased function of SA & AV nodal cells increasing risk of dysrhythmias • Cardiac output decreased by 30%

29. Arteries become increasingly rigid • Increased blood pressure to pump through rigid blood vessels • Reduced blood flow to all organs • Decreased peripheral resistance • Widened pulse pressure - increasing systolic blood pressure • Heart muscle stiffens • Postural hypotension - vessels less reflexive and blood pressure drops when patient stands up too fast • Atherosclerosis - progressive, degenerative disease of medium and large sized arteries

30. Cardiovascular Disease • Risk factors for developing cardiovascular disease • Previous MI • Angina • Diabetes • Hypertension • High cholesterol level • Smoking • Sedentary lifestyle

31. Geriatrics and Acute Myocardial Infarctions • Elderly do not present with typical signs or symptoms of acute myocardial infarctions • Silent MI’s are marked by atypical complaints such as fatigue, nausea, abdominal pain and breathlessness • High index of suspicion for MI with unusual or absent warning signs/symptoms • Mortality doubles after age 70

32. Heart Failure • A clinical syndrome where the heart’s mechanical performance (pumping) is compromised and cardiac output cannot meet the body’s needs • Caused by: ischemia, valvular disease, dysrhythmias, hyperthryoidism, anemia, cardiomyopathy • In elderly, large incidence of non-cardiac causes • Generally divided into right and left heart failure • Ventricular output insufficient to meet the metabolic demands of the body

33. Heart Failure • Left ventricular failure • left ventricle fails as a forward pump • back pressure of blood in the pulmonary system leads to pulmonary edema • Right ventricular failure • right ventricle fails as a forward pump • back pressure of blood into the systemic venous circulation leads to venous congestion • Congestive heart failure • reduced stroke volume causes an overload of fluid in body tissues

34. Signs and Symptoms of Heart Failure • Dyspnea • Fatigue • Orthopnea - often sleeping on extra pillows to be more upright • Dry, hacking cough progressing to frothy sputum • Dependent edema due to right heart failure (check most dependent part of body depending on mobility - feet or sacral area) • Nocturia - urinating at nighttime • Anorexia, ascites (fluid in abdomen)

35. EMS Protocol Treatment Pulmonary Edema • Routine medical care • Oxygen via nonrebreather initially • BVM and intubation if needed • Stable patient with B/P >100 systolic • Nitroglycerin 0.4 mg sl (can repeat every 5 minutes to a maximum of 3 doses) • venodilator - reduces return of blood to heart to reduce workload of heart • Lasix 40 mg IVP (80 mg if on lasix) • diuretic and venodilator - reduces fluid return & workload on the heart

36. Pulmonary Edema cont’d • Stable patient cont’d • IfB/P >100 systolic, morphine 2 mg slow IVP • repeat 2mg every 3 mins as needed; max 10 mg • reduce anxiety; venodilator • Consider CPAP if B/P > 90 • Unstable patient B/P <100 systolic • contact medical control • consider cardiogenic shock protocol • dopamine drip to raise blood pressure • fluid challenge would not be appropriate in patient with crackles/rales (wet lungs) • treat dysrhythmias as they present

37. Dysrhythmias and Geriatrics • Common dysrhythmias • PVC’s when over 80 years old • atrial fibrillation - increased risk for stroke • Morbidity/mortality • Serious due to decreased tolerance due to decreased cardiac output • The cerebral hypoperfusion leads to an increase in falls • Can lead to TIA’s and CHF (ineffective pumping)

38. Aneurysm • A bulge in a blood vessel; if large enough can put pressure on surrounding structures • May be aortic or cerebral • Associated risk factors • Smoking • Hypertension • Diabetes • Atherosclerosis • Hyperlipidemia • Polycythemia • Heart disease

39. Hypertension • Blood pressure ranges • optimal <120/<80 • normal range <135/<85 • hypertensive range >140/>90 • Risk factors for developing hypertension • African Americans • elderly • geographics (Southeastern United States) • males (after menopause, women equally vulnerable) • socioeconomic status - lower the status the greater the risk

40. Hypertension • Morbidity/mortality • B/P greater than 160/95 doubles mortality in men • If blood pressure remains uncontrolled, damage seen to circulation (vascular system) and organs • cardiovascular disease (CVD) - stroke, MI, heart failure • end-stage renal disease

41. Hypertension • Awareness of the disease, it’s treatment, and control have improved but are still suboptimal • Prevention and control • Regular physical check ups • Follow medication routine if prescribed • Weight control • Exercise • Decreasing salt intake • Socially/emotionally active • Smoking cessation • Decreasing alcohol consumption

42. Hypertensive Emergencies • Definition • acute elevation of systolic blood pressure >230/>120 • Signs & symptoms • epistaxis (nosebleed) • headache • visual disturbances • neurological changes - altered mental status and seizures • nausea & vomiting

43. SOP Treatment Hypertensive Emergencies • Routine medical care: IV-O2-monitor • Blood pressure in both arms and record • keep arm level with the heart • Vital signs and neuro status every 5 minutes • P-R-B/P-mental status-pupillary response-GCS • Lasix 40 mg IVP (80mg if on Lasix at home) - diuretic & vasodilator • If Medical Control orders, give NTG sl- vasodilator

44. Stroke - Cerebrovascular Accident • 3rd leading cause of death in the USA • Occlusive stroke - 80% incidence • causes brain ischemia • time to hospital treatment (TPA - fibrinolytic clot bluster) must be <3 hours from time of onset • most important question - “what time did the symptoms start?” • Hemorrhagic stroke - 20% incidence • higher percentage of death

45. Risk Factors For Stroke • Elderly • Atherosclerosis • Hypertension • Immobility • Limb paralysis • Congestive heart failure • Atrial fibrillation • Diabetes • Obesity

46. Signs and Symptoms of Stroke • Elevated blood pressure • Altered mental status or mood • Coma • Paralysis or extremity weakness • Slurred speech • Seizures Note: Suspect stroke in any elderly person with a sudden change in mental status. Always check blood sugar level in setting of altered mental status

47. Cincinnati Stroke Scale Assessment • Facial droop - have patient smile big enough to show their teeth • Arm drift - patient closes their eyes and extends arms out straight, palms facing up for 10 seconds • Abnormal speech - have the patient repeat back a response given (speech may have already been detected during normal conversation)

48. Documentation of Cincinnati Stroke Scale Results • Facial droop • right, left, or no droop present • Arm drift • right, left, or no arm drift • Abnormal speech • slurred speech or clear speech • Even normal responses with no deficits must be documented to show the assessment was performed

49. Endrocrine Emergencies in Geriatrics • Diabetes and Thyroid Disease • Due to the aging process and multiple disease processes the signs and symptoms may not appear to be classic • Suspect thyroid disease in an elderly patient who has vague symptoms of “illness” • 20% of the elderly have diabetes • 40% have impaired glucose tolerance • Type II (non-insulin dependent) is the most common form of diabetes and related to obesity

50. Hyperthyroidism Weight loss Mentation changes - nervousness, irritability Tachydysrhythmias, palpitations Hyperactivity, nervousness, irritability Heat intolerance Abdominal pain Diarrhea Weak leg muscles perspirations Hypothyroidism Low metabolic state  appetite with weight gain Vague musculoskeletal complaints Lethargy, fatigue, sluggishness Cold intolerance Constipation Anemia Depression, forgetfulness Hyponatremia ( Na) Moon face Endocrine Disorders