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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 Slide 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 Slide 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 Slide 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 Slide 5 Patients With Special Challenges - Visual Impairment Etiologies Injury Disease Degeneration of eyeball, optic nerve or nerve pathways Congenital Infection (C.M.V.) Slide 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 Slide 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 patients special needs Carefully lead patient when ambulatory patient holds your arm call out obstructions, steps and turns ahead of time Slide 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 Slide 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 Slide 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 Slide 11 Utilizing Translation Line Slide 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 Slide 13 Obesity Risk Factors Hypertension Stroke Heart disease Diabetes Some cancers Kidney failure Slide 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 Slide 15 Breathing Considerations in Obesity Lungs 35% less compliant Increased weight of the chest Increased work of breathing Hypoxemia common O 2 sats not reliable on finger tips (poor circulation) Diaphragm higher Slide 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 Slide 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 Slide 18 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 Transport Considerations in Obesity Slide 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 Slide 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 Slide 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 Slide 22 Assessment/Management Accommodations - Mental Illness Solicit permission before beginning care Gain rapport/trust but your safety is first Dont make promises you cant keep Dont 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 Slide 23 Patients With Special Challenges - Downs 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 Slide 24 Assessment/Management Accommodations - Downs Syndrome Congenital heart, intestinal, hearing defects Limited learning capability Generally affectionate and friendly Utilize patience with assessment Explain procedures before beginning task Slide 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 Slide 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 Slide 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 Slide 28 Etiologies Emotionally/Mentally Impaired contd Poverty/cultural deprivation Malnutrition Disease-producing conditions (lack of cleanliness) Inadequate medical care Environmental health hazards Lack of stimulation Slide 29 Patients With Special Challenges - Emotionally or Mentally Impaired Assessment/management accommodations Chronological age may not be consistent 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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) Slide 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 Slide 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 UTIs Slide 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 Slide 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 Slide 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 Slide 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 nerve impulses Slide 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) Slide 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 Slide 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 Slide 49 Patients With Special Challenges Financial Challenges A patients 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 Slide 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 Slide 51 Patients With Financial Challenges Resources Payment programs may be available Government services are available to assist What does your township office offer? Free (or near-free) health care services available through local, state and federally-funded organizations Slide 52 Interventions for the Specially Challenged and Chronic Care Patient Slide 53 Home Healthcare Providers Home health providers know the equipment in the home They know the patient and the normal state of holistic health Can make a quick response to acute changes in status Often highly trained providers They can be a great resource Slide 54 EMS vs. Home Healthcare Both have to compliment each other to provide high level of care to the patient By being integral parts to the overall care delivery system, the patient gets ultimate care If either decides their job is more important, the delivery of care diminishes Slide 55 Healthcare Delivery Training or education possibilities Registered nurse (hospice oriented) Registered respiratory therapist Certified nurses aid (CNA) Registered occupational therapist Registered speech pathologist Licensed paramedic (EMT) Certified nursing assistant (CNA) Slide 56 Delivery of Home Healthcare Benefits of home health care Early disposition of acute health problems Socialization of home-bound client Family members can be more involved Patient gets to stay at home while recovering from illness or injury Less stress to the patient Slide 57 Delivery of Home Healthcare Deficiencies in care Cost Variety of levels and competencies of healthcare providers Low pay to the provider Incompetence of provider Family members not in agreement with care Complications Inadequate recognition of acute illness Theft to the patient Slide 58 In-hospital vs. Homecare Mortality and quality Higher incidence of infection as an in- patient Quality of care depends on competence of the provider in each situation Can be very supportive and actually diminish the instance for hospitalization if the home care provider is aggressive Less stress on the patient to be cared for at home Slide 59 Home Care Equipment Nearly any piece of equipment found in a hospital can be used at home Complications and pathologies to summon EMS support Inadequate respiratory support Acute cardiac events Acute sepsis GI/GU crisis Home dialysis emergencies Displaced catheters or G/J-tubes Slide 60 Home Care Airway Adjuncts Oxygen delivery devices CPAP machine (mask and nasal) BiPAP machine Tracheotomies Home ventilators Peak flow machine Slide 61 Vascular Access Devices Central venous access devices Hickman, Groshon Directly into central circulation Often surgically implanted Dialysis shunts - usually forearm, may be abdominal placement PICC access device Peripheral line Generally in antecubital Peripheral venous IV Slide 62 Nutrition (Delivery/Removal) Gastric emptying or feeding NG tubes Feeding tubes PEG tubes (J-tubes) Colostomy Urinary tract Internal/external catheters Suprapubic catheters Urostomy - collection bag worn PEG tubes Slide 63 Urinary Catheter Insertion Indications Ability to monitor output Incontinence Decreased level of consciousness Frequency Contraindications Inability to care for insertion site Increases risks of infections that could lead to sepsis Slide 64 Assessing Complications of the Airway Evaluate Respiratory effort Tidal volume Peak flow Oxygen saturation Breath sounds Compare values based on the patients normal or baseline levels Slide 65 Assessing Complications of Vascular Access Devices Infection/sepsis Inadvertent removal Hemodynamic compromise Hemorrhage Embolus Stable vs. unstable angina Improper fluid administration Inability of home caregiver to flush device PICC line Slide 66 Assessing Complications of GI/GU Devices Abdominal pain Inability of caregiver to flush device Distention Lack of bowel sounds Palpation of bladder indicating fullness Change in color/character/amount of urine Redness/discharge at insertion sites Slide 67 Ventilatory Devices Recognizing device or patient failure Inadequate oxygenation Anxiety Hypoventilation Management Reposition airway Remove secretions - suction Support ventilations with BVM May need to transport patient to hospital with their ventilator - will it fit in rig? Consider using home caregiver to continue assisting in providing care Slide 68 Rights of the Terminally Ill Right to refuse care Right to comfort Right to advanced healthcare They need family support as well as integrated healthcare team Hospice care Comfort care Slide 69 Hospice care Definition The ability to provide care for a patient in a comfort type of environment as the disease process is in an advanced stage Patient usually terminal within 6 months Care is patient and family centered Palliative & comfort care is necessary Slide 70 Hospice Care Employs team of caregivers Advanced directives followed to honor the patients wishes Family is very involved in process of care Disease process not limited to cancer care only Family may call 911 for acute problem (dyspnea, chest pain) that needs to be attended to with full care provided prior to arresting Involves great deal of emotional support Slide 71 DNR/DNAR Do not attempt resuscitation Does not mean do not treat medical conditions The DNR form must be the State form including the patient name, patient signature, date, doctors signature and the words do not resuscitate CPR must be started in the absence of a valid, signed DNR form except for decapitation, rigor mortis without hypothermia, dependent lividity, body decompensation, incineration Slide 72 Patients with Special Challenges and Chronic Care Needs