Transcript Patients With Special Challenges and Interventions for Patients with

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
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
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
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
Patients With Special Challenges Visual Impairment
• Etiologies
– Injury
– Disease
– Degeneration of
eyeball, optic nerve
or nerve pathways
– Congenital
– Infection (C.M.V.)
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
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 of time
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
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
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
Utilizing Translation Line
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
Obesity Risk Factors
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Hypertension
Stroke
Heart disease
Diabetes
Some cancers
Kidney failure
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
Breathing Considerations in Obesity
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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
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
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
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
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
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
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 “intouch” with reality; patients are aware
of their illness
– depression, phobias,
obsessive/compulsive disorder
Assessment/Management
Accommodations - Mental Illness
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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 nonprescription 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
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
Assessment/Management
Accommodations - Down’s
Syndrome
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Congenital heart, intestinal, hearing defects
Limited learning capability
Generally affectionate and friendly
Utilize patience with assessment
Explain procedures before beginning
task
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
Patients With Special Challenges Multiple Sclerosis
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Progressive/incurable autoimmune disease
Brain and spine myelin destroyed
May be inherited or viral component
Begins in early adulthood
Physical/emotional stress exacerbates
severity
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
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
Patients With Special Challenges Muscular Dystrophy
• Signs and Symptoms
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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
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
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
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)
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
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
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
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
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
Interventions for the
Specially Challenged and
Chronic Care Patient
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
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
Healthcare Delivery
• Training or education possibilities
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Registered nurse (hospice oriented)
Registered respiratory therapist
Certified nurses aid (CNA)
Registered occupational therapist
Registered speech pathologist
Licensed paramedic (EMT)
Certified nursing assistant (CNA)
Delivery of Home Healthcare
• Benefits of home health care
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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
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
In-hospital vs.
Homecare
• Mortality and quality
– Higher incidence of infection as an inpatient
– 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
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
Home Care Airway Adjuncts
• Oxygen delivery devices
• CPAP machine
(mask and nasal)
• BiPAP machine
• Tracheotomies
• Home ventilators
• Peak flow machine
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
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
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
Assessing Complications of
the Airway
• Evaluate
– Respiratory effort
– Tidal volume
– Peak flow
– Oxygen saturation
– Breath sounds
• Compare values based on the patient’s
“normal” or baseline levels
Assessing Complications of
Vascular Access Devices
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Infection/sepsis
Inadvertent removal
Hemodynamic compromise
Hemorrhage
Embolus
Stable vs. unstable angina
Improper fluid administration
Inability of home caregiver to
flush device
PICC line
Assessing Complications of
GI/GU Devices
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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
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
Rights of the Terminally Ill
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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
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
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
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, doctor’s 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
Patients with Special
Challenges and Chronic
Care Needs