Transcript Culturally Diverse Patients

Curriculum Update:
Culturally Diverse Patients
Geriatric Population
Medications for Home Use
Condell Medical Center EMS System
March 2006
Site Code #10-7200-E-1206
Revised by Sharon Hopkins, RN, BSN
EMS Educator
Objectives
Upon successful completion of this module,
the EMS provider should be able to:
• understand the sensitivity required when
caring for a culturally diverse patient
population.
• discuss the unique assessment and care
necessary for the geriatric population
• discuss common medications taken by the
population and potential impacts with
clinical presentations
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
Culturally Diverse Patients
• Key points
• Individual is the “foreground”, culture is the
“background”
• All people share common problems/situations
• Not all people identify with their ethnic
cultural background
• Every patient needs to be treated equally
• Do not force someone
to have an intervention
that is against their
personal beliefs
Culturally Diverse Patients
• 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 EMS signs and adds the name of
the person supplying permission
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
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 - know your own
department’s resources
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
community
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
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)
• Asians may be reluctant to make eye
contact with a figure of authority
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
Smiling and Winking
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Japanese - may smile when confused or angry
Others Asians - smile in friendly greeting
Latin Americans - winking is romantic, sexual
Nigerians - parents wink at children to have
them leave the room
Chinese - winking is rude
Hong Kong - blinking is sign of disrespect and
boredom
Filipinos - point to objects with eyes, not
fingers
Venezuelans - finger pointing is impolite
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
Body Language - Posture
• Range of attitudes conveyed from interest,
respect, subordination, disrespect
• Argentina - standing hands on hips suggests
anger or a challenge
• Taiwan - good posture extremely important
• Some cultures impolite to show the bottom of
the shoe because it is dirty; will not sit with a
foot resting on opposite knee
Body Language - Gestures
• Can replace or accompany verbal
communication
• Japan - rude to pass an item with one hand
• Middle & Far Eastern cultures - left hand
considered unclean - rude to pass items with
left hand
• In Europe, waving goodbye is raising the hand
palm facing out, wiggling fingers back and
forth
• In Nigeria, this is an insult if the hand is too
close to another’s face
Gestures
• In Bulgaria & Greece, head nodding means no
• In the USA, beckoning with 1 finger means
“come here”. In some cultures it is insulting or
obscene.
• Indonesia - pointing is done with a thumb
• Middle East - pointing with 1 finger is impolite
• “OK” sign
– obscene in Germany and Bulgaria
– in Japan means zero or worthless
Cultural Diversity - Physical
Contact
• Eastern Europeans are comfortable with
touching
• Asians prefer less physical contact
• Chinese are uncomfortable with physical
contact but will use a handshake for greeting
• Latin Americans show affection easily and
handshakes are strong & warm
• Egypt - tend to be touch oriented
Cultural Diversity - Gestures
• Middle East - left hand reserved for
hygiene. Don’t shake hands left-handed
or accept a gift with left hand
• Native Americans - offensive to step on
a foot - apologize immediately
Culturally Diverse Patients African Americans
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Handshaking is appropriate
Eye contact is appropriate
Culture vocally expressive
Close friends tend to be viewed as “family”
Tends to be matriarchal society
Skeptical of westernized medicine
Culturally Diverse Patients Arab Americans
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Prefer handshaking
Direct eye contact acceptable
Verbally expressive
Family shares in decision making process
Folk remedies are common
– soup, prayer
• Fond of westernized medicine
Culturally Diverse Patients Chinese Americans
• Direct eye contact and speaking out may
be viewed as being disrespectful
• Nodding is a sign of respect and not
understanding
• Oldest males in the group make decisions
• Folk remedies are common
• May interact with westernized medicine
Culturally Diverse Patients Mexican Americans
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Handshaking is appropriate
May avoid eye contact out of respect
Tends to not complain of pain
Silence is maintained out of respect or
due to not understanding
• Males usually head of the household
• Folk remedies are common
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
Culturally Diverse Patients Financially Challenged
• Signs of impairment
– homelessness
– chronic illness with frequent
hospitalizations
– poor personal hygiene
– self-employment
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 selfsufficiency with safe, affordable permanent
housing
• HealthReach Clinic - medical screening
• 847-360-8800 (Waukegan)
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
Culturally Diverse Patients
• During Assessment and Management
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Recognize need for assistive devices
Respect the patient’s beliefs
Ask permission to initiate procedures
Obtain interpreter if unable to communicate
because of language barrier
• Allow ample time and area of
privacy
• Notify receiving hospital of
special needs
Groups By Region
• Asian
– Afghanistan, Armenia, Azerbaijan, Bahrain,
Bangladesh, Bhutan, Brunei, Burma, Cambodia,
China, Georgia, Hong Kong, India, Indonesia,
Iran, Iraq, Israel, Japan, Jordan, Kazaksta, North
Korea, South Korea, Kuwait, Kyrgyzstan, Laos,
Lebanon, Malaysia, Maldives, Mongolia,
Myanmar, Nepal, Oman, Pakistan, Phillipines,
Qatar, Russia, Saudi Arabia, Singapore, Sri
Lanka, Syria, Taiwan, Tajkistan, Thailand,
Turkey, Turkmenistan, United Arab Eminates,
Uzbekistan, Vietnam, Yemen
Groups By Region
• Far East - the “orient” - East Asia and
Southeast Asia
– Brunei, Cambodia, People’s Republic of China,
Republic of China, East Timor, Hong Kong,
Indonesia, Japan, Korea Laos, Macau,
Malaysia, Myanman, Phillipines, Thailand
Vietnam
• Asian American – term used to describe East Asian peoples; older
term was “oriental”
– term refers to person of that ethnic decent
born in or immigrated to the United States
Groups By Region
• Eastern European
– Albania, Belarus, Bosnia & Herzegovina,
Bulgaria, Croatia, Czech Republic,
Estonia, Hungary, Lataiva, Lithuania,
Macedonia, Moldova, Poland, Romanis,
Russia, Serbia & Montenegro, Slovakia,
Slovenia, Ukraine
Groups By Region
• Middle East - South & Central Asia,
Southwest Asia, & Egypt
– Bahrain, Cyprus, Egypt, Iran, Iraq, Israel,
Jordan, Kurdistan Region, Kuwait, Lebanon,
Oman, Palestinian Territories, Qatar, Saudi
Arabia, Syria, Turkey, United Arab Emirates,
Yemen
• Native American
– a person having origin in any of the original
peoples of North American and who maintain
cultural identity through tribal affiliation or
community recognition
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
Geriatrics
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
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
lose of independence
Challenges in the Geriatric
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
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
• Taste & smell
– altered (decreased sensitivity)
– creates decreased appetite which causes poor
nutritional condition
• Touch
– neuropathies cause decrease 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
Communicating with the
Geriatric Population
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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
Evaluating the Environment
• Condition, cleanliness & safety
of housing arrangement
• Nutritional status & evidence of food
quality & quantity in the home
• Personal hygiene & evidence of ability
to maintain self independently
• Multiple prescription bottles with
multiple prescribers noted
– drugs may be negatively interacting
if the patient has not informed all
physicians of all medications they
are taking
Obtaining A History in the
Geriatric Population
• Resources for medical information
– “Vial of life” - form of vital medical &
personal information placed in a container that
is kept in refrigerator
• red heart-shaped magnet placed on outside
of refrigerator
– medic alert tags
• custom engraved bracelet or necklace with
important information on medical
conditions, drug & food allergies,
prescribed medications, emergency
contacts
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
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
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%
• 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
Cardiovascular Disease
• Risk factors for developing cardiovascular
disease
• Previous MI
• Angina
• Diabetes
• Hypertension
• High cholesterol level
• Smoking
• Sedentary lifestyle
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
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
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
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)
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
Pulmonary Edema cont’d
• Stable patient cont’d
– If B/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
Dysrhythmias and Geriatrics
• Common dysrhythmias
– PVC’s when over 80 year 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)
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
Hypertension
• Blood pressure ranges
– optimal <120/<80
– normal range <135/<85
– hypertensive range >140/>90
• Risk factors for developing hypertension
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African Americans
elderly
geographics (Southeastern United States)
males (after menopause, women equally
vulnerable)
– socioeconomic status - lower the status the
greater the risk
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
Hypertension
• Awareness of the disease, it’s treatment, and
control have improved but are still
suboptimal
• Prevention and control
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Regular physical check ups
Follow medication routine if prescribed
Weight control
Exercise
Decreasing salt intake
Socially/emotionally active
Smoking cessation
Decreasing alcohol consumption
Hypertensive Emergencies
• Definition
– acute elevation of systolic blood pressure
>230/>120
• Signs & symptoms
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epistaxis (nosebleed)
headache
visual disturbances
neurological changes - altered mental
status and seizures
– nausea & vomiting
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-AVPU status-pupillary response-GCS
• Lasix 40 mg IVP (80mg if on Lasix at
home) - diuretic & vasodilator
• If Medical Control orders, give NTG slvasodilator
Stroke - Cerebrovascular
Accident
• 3rd leading cause of death in the USA
• Occlusive stroke - 80% incidence
– causes brain ischemia
– time to hospital treatment (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
Risk Factors For Stroke
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Elderly
Atherosclerosis
Hypertension
Immobility
Limb paralysis
Congestive heart failure
Atrial fibrillation
Diabetes
Obesity
Signs and Symptoms of Stroke
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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
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 for 10
seconds
Abnormal speech - have the patient
repeat back a response given (speech
may have already been detected during
normal conversation)
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
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
Endocrine Disorders
• Hyperthyroidism
• Hypothyroidism
– Weight loss
– Mentation changes nervousness, irritability
– Tachydysrhythmias,
palpitations
– Hyperactivity,
nervousness, irritability
– Heat intolerance
– Abdominal pain
– Diarrhea
– Weak leg muscles
– perspirations
– Low metabolic state
–  appetite with weight gain
– Vague musculoskeletal
complaints
– Lethargy, fatigue, sluggishness
– Cold intolerance
– Constipation
– Anemia
– Depression, forgetfulness
– Hyponatremia ( Na)
– Moon face
Endocrine Complications &
Prevention
• Hyperthyroidism
– impaired glucose tolerance problems with sugar processing
(“pre-diabetic” condition)
– type II diabetes
– tachycardia
– atrial fibrillation
• Hypothyroidism
– bradycardia
• Prevention
– maintain healthy weight
– remain compliant with medication regime
– maintain healthy lifestyle
– excercise
Integumentary (skin)
Emergencies
• Risk factors
– Epidermal cellular turnover decreases
– Slower wound healing
– Increased risk for secondary infection
– Increased risk of skin tumors, fungal or
viral infections
– Hair becomes finer and thinner
Pressure Ulcers
• Results from hypoxia to tissue cells
• Usually over bony areas
• Common in immobile patients
– those confined to bed or wheelchairs
• Increased incidence in patients with:
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altered sensory perception
skin exposure to moisture, especially prolonged
decreased activity & inability to shift positions
poor nutrition
friction or shear (ie: being pulled and dragged
across a surface instead of being lifted)
Prevention of
Pressure Ulcers
• Immobile patients turned every 2-4 hours
• Adequate hydration and nutrition
provided
• Personal hygiene maintained
• Environment kept clean
• Insure immobile patients do not have
wrinkled bedsheets or clothes
• Prescribed antibiotics or medications
provided as ordered
Traumatic Deaths in Geriatrics
• Trauma is the fifth leading cause of death
• Mortality rates markedly increased in the elderly
• One-third of traumatic deaths are in 65 - 74 year
olds secondary to vehicular trauma
• 25% result from falls
• 50% of persons >80 years old
die from falls
• Post-injury disability more
common in the elderly
Risk Factors Related to Trauma
• Osteoporosis and muscle weakness increases the
risk of fractures
– women more vulnerable after menopause
– men are also at risk for this disease
• Reduced cardiac reserve decreases ability to
compensate for blood loss
• Decreased respiratory function increases risk for
adult respiratory distress syndrome (ARDS)
• Impaired renal function decreases ability to
adapt to fluid shifts
• Unsteady gait increases risks of falls
Traumatic Emergencies
– Orthopedic Injuries
• Pelvic fractures are highly lethal due to severe
hemorrhage and associated soft tissue injury
• Decreased pain perception may mask major
fracture
• A large percentage of elderly will die within
one year of a hip fracture
Orthopedic Injuries
• Hip fractures most common acute injury
• Elderly are susceptible to stress fractures of
femur, pelvis, tibia
• Packaging should include adding bulk and
padding between the patient and the back
board
• Kyphosis (rounding of the back) may
require extra padding under shoulders to
maintain alignment
– often caused by osteoporosis, arthritis,
vertebral slippage
External
Rotation
Fracture site
Fracture
repaired with
plate &
screws
Orthopedic Injuries From Falls
• Major cause of morbidity/mortality
• 10,000 deaths each year
• One third of elderly fall at home each year
– 1 in 40 are hospitalized
– Cause significant mobility problems
and functional dependence
• Evaluate home for safe conditions
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use of non-skid rugs
adequate lighting - hallways and at night
sturdy hand rails on stairs and in bathrooms
items within reach (ie: kitchen)
environment clear of clutter
Traumatic Head Injuries
• Poorer outcome when injury associated
with loss of consciousness
• Brain shrinkage as one ages allows more space
and greater brain movement
• Increased incidence of subdural hematoma
–  frequency of falls lead to more head injuries
– brain shrinkage allows for more room to bleed
– bleeding is venous - slow development of
symptoms
• headache
• mental status changes
Spinal Column Injuries
• Progressive arthritic and
degenerative changes and
osteoporosis associated with the
aging process lead to higher
incidence of bony injuries
• Injuries have a negative impact on
the function and quality of life
• Pain  ability to perform
activities of daily living
• A psychosocial impact and threat
to loss of independence
Compression Fractures of Spine
• Occurs in 25% of post-menopausal women in the
USA (up to 40% in women over 80)
• Applied force may be minimal (lifting an object,
stepping out of tub, sneezing) or more significant
(major fall, MVC)
• Acute onset low back pain, tenderness to palpation
usually over T 8-12 and L 1-4
• Rarely neurological symptoms
• Transport in position of most comfort
• Treatment symptomatic & conservative rest, pain control, physical therapy
Burns in the Elderly
• 1000 die each year from home fires
• People over 60 have higher mortality
rate from burns
• Increased morbidity/mortality due to
preexisting disease, skin changes
(thinning & slower healing time),
altered nutrition, increased risk to
infection, decreased reaction time to
move away from source
Treatment of Burn Injuries
• Fluid important to prevent renal tubular
damage from altered blood flow through
the kidneys
• Normal aging changes cause a
decreased response in heart rate and
stroke volume to hypovolemia
• Hydration assessed in initial hours after
burn injury by B/P, pulse, and urine
output (1-2 ml/kg/hour minimally)
• Rapid IV administration may cause
volume overload (monitor lung sounds
and vital signs frequently)
Burn Injury Prevention
• Install fire alarms in residence - 1 per floor
• Practice fire safety with appliances,
candles, cigarettes, lighters
• Never leave food unattended on stove
• Do not cook while wearing baggy sleeves
• Practice fire evacuation routes
• Install easy to read phones to dial 911
• Investigate need for Lifeline assistance
– way for senior to contact help when
needed
Toxicology & Geriatrics
• Alterations in body composition, drug
distribution, metabolism and excretion
increases the risk for toxicity in elderly
when exposed to over-the-counter
medications, prescription medications, and
other substances
Risk Factors Related To Toxicology
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•
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Decreased kidney function alters elimination
Increased likelihood of CNS side effects
Altered GI absorption
Decreased liver blood flow alters metabolism and
excretion
• History of alcoholism
• Vision and memory changes
result in noncompliance
• Poor dexterity and eyesight decreases
ability to choose correct medication and/or dosage
Prevention
• Label medications clearly and in larger print
• Provide assistance with nutrition and
medication administration as needed
• Consult with physician frequently
• Make sure all physicians are aware of all
medications taken
– over-the-counter; prescription;
remedies
• Limit OTC drug administration
• Segregate storage in medicine
cabinet
– ingested medications on one shelf
– topical medications on a different shelf
herbal
Elder Abuse
• May occur in home or institutional setting
• EMS is mandated by State of Illinois to report
suspicions to hot line
• Abuse
– any physical injury, sexual abuse or mental
injury inflicted on a person, aged 60 or older,
other than by accidental means
• Neglect
– failure to provide adequate medical or personal
care or maintenance in which failure results in
physical or mental injury or deterioration of
condition
Elder Abuse Reporting
• Document objectively and describe
injuries using measurements and colors
and not vague terms
• Report suspicions to ED staff
• Abuse Hot Line
– M-F 0830 - 1700: 1-800-252-8966
– All other times:
1-800-279-0400
Medications for Home Use
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•
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•
•
Antidepressants
Antianxiety
Anticoagulants
Lipid management
ACE inhibitors
Beta blockers
Calcium channel
blockers
• Diuretics
• GI system
• Insomnia and sleep
disorders
• Erectile dysfunction
Medications for Home Use
• Antidepressants
– depression is a chronic illness of feeling
hopeless and of losing interest
– SSRI (selective serotonin reuptake inhibitors)
• improves mood
• lexapro, prozac, paxil, zoloft
– Tricyclic antidepressants
• amitriptyline, nortriptyline
– MAO inhibitors
• could have potentially life-threatening drug
& food interactions
• nardil, parnate
Medications for Home Use
• Antianxiety
– to relieve anxiety
– benzodiazepines most common category
• Anticoagulants
– to inhibit the ability to clot; does not dissolve
an existing clot
– coumadin, lovenox, heparin, plavix, aspirin
Medications for Home Use
• Lipid management
– to reduce cholesterol and LDL levels
which when elevated increases risks of
coronary heart disease (CHD)
– statins: lipitor, lescol, zocor, pravachol,
mevacor, baycol, crestor, pitava
– non-statin: zetia, niacin, velchol,
torcetrapib, panavir
Medications for Home Use
• ACE inhibitors
– allow blood vessels to enlarge or dilate to
decrease B/P
– used to control B/P, treat heart failure,
prevent kidney damage in hypertensive &
diabetic patients
– catopril (capoten), lotensin, vasotec,
lisinopril (prinivil & zestril), monopril,
ramipril (altace), aceon, accupril, univasc,
mavik
Medications for Home Use
• Beta blockers
– relieves stress on heart by blocking some
involuntary nervous system control on the heart
– slows heart rate, decreases force of
contractions, reduces blood vessels contractions
– used to treat cardiac dysrhythmias, atrial
fibrillation, hypertension, angina, post-MI
(reduces morbidity), glaucoma, migraines,
anxiety
– most generic names end in “olol”
– atenolol (tenormin), metoprolol (lopressor),
propranolol (inderal), nadolol (corgard),
carvedilol (coreg)
Medications for Home Use
• Calcium channel blockers
– block entry of calcium into muscle cells of
heart and arteries to decrease the strength
and rate of heart contractions and dilate
arteries
– used to treat high blood pressure,
arrhythmia (atrial fibrillation), angina,
used post-MI
– verapamil (calan, isoptin), diltiazem
(cardizem), nifedipine (procardia),
bepridil (vascor), amlodipine (norvasc)
Medications for Home Use
• Diuretics
– to reduce the vascular fluid volume
– used to treat heart failure, hypertension, fluid
retention
– aldactone, aldactazide, bumex, diuril,
hydrochlorothiazide, HCTZ, hydrodiuril,
dyazide, dyrenium, lasix (furosemide)
• Diabetes
– inadequate insulin activity for glucose
metabolism
– actos, amaryl, avandia, diabeta, glucophage,
glucotrol, prandin, precose, starlix
Medications for Home Use
• GI system
– to treat acid reflux, excess acid, GERD,
irritable bowel
– aciphex, asacol, mylanta, pepcid,
prevacid, prilosec, propulsid, reglan,
rolaids, tagamet, tums, zantac, lomotil,
bentyl, imodium
Medications for Home Use
• Insomnia and sleep disorders
– sleep deprivation affects the body’s metabolism
– insomniacs are at increased risk for host of
diseases; decreases motor skill and affects
memory and mental performance
– being awake 24 hours is equivalent to a blood
alcohol level of 0.1
– ambien, halcion, restoril, lunesta
benzodiazepines like lorazepam (ativan),
diazepam (valium)
Medications for Home Use
• Erectile dysfunction
– to improve erectile function (impotence) in men
and sexual arousal in women
– increases amount of blood flow, does not
automatically produce an erection but allows one
after physical and psychological stimulation
– not to be taken if MI, stroke or life-threatening
dysrhythmia in last 6 months
– not to be mixed with nitrate use (NTG) in same 24
hours period -blood vessel dilation could be too
much to reverse & could cause death
– viagra (sildenafil), cialis, levitra
Pearls of Medication
• Benzodiazepines
– use mixed with alcohol increases depressant
effects - watch for respiratory depression
• Anticoagulants
– increases risk for bleeding complications
• Beta blockers
– patient won’t respond with tachycardia even in
shock due to effects of drugs
• Hypertensive patient
– a normal reading (ie: 110/80) may be shock
for the patient with a chronically elevated
blood pressure
Medications
• Important to remember to bring in all
medications from the patient’s home
– prescription
– herbal remedies
– non-prescription over-the-counter
• Hospitals are working hard on helping
patients get a handle on their
medications and trying to avert possible
unhealthy interactions
References
• Bledsoe, B. E., Porter, R. S., Cherry, R. A. Paramedic Care
Principles & Practices. Brady 2006.
• www.aafp.org
• www.allaboutvision.com
• www.americanheart.org
• www.aoa.org/documents/CPG-8.pdf
• www.clara.abbott.com
• www.dynomed.com/encyclopedia/encyclopedia/spine/
Compression_Fracture.htm
• www.glaucoma.org
• www.nihseniorhealth.gov
• www.nlm.nih.gov/medlineplus/cataract.html
• www.pads-crisis-services.net
• www.richmondeyecare.com/vets2html
Cultural Diversity, Geriatrics,
Home Medications