1. Special Patients

2. Hearing impairments

3. n n Types Conductive deafness Sensorineural deafness

4. Etiologies n n Conductive deafness (curable) Infection Injury Earwax

5. Etiologies n n Sensorineural deafness (many incurable) Congenital Birth injury Medication-induced Viral infection Tumors Prolonged exposure to loud noise Aging

6. Recognition n n Hearing aids n n Poor diction n n Inability to respond to verbal communication in absence of direct eye contact

7. Accommodations n n Retrieve hearing aid n n Paper/ pen n n Maintain position so patient can read lips n n Use of an “amplified” listener n n Picture of basic needs/ procedures

8. Accommodations n n American Sign Language (ASL) n n Interpreter Notify receiving facility as early as possible

9. Accommodations n n Do not shout 80% of hearing loss is related to loss of high-pitched sounds Use low-pitched sounds directly into ear canal n n Do not exaggerate lip movement

10. Visual impairments

11. Etiologies n n Congenital n n Injury n n Infection (C.M.V.) n n Glaucoma n n Degeneration of eyeball, optic nerve or nerve pathways

12. Accommodations n n Retrieve visual aids n n Describe everything you're going to do n n Provide sensory information n n If ambulatory, guide by leading, not by pushing n n Allow guide dogs to accompany patient

13. Speech impairments

14. Types n n Language disorders n n Articulation disorders n n Voice production disorders n n Fluency disorders

15. Language disorders n n Etiologies Stroke Head injury Brain tumor Delayed development Hearing loss Lack of stimulation Emotional disturbance

16. Language disorders n n Recognition Slowness to understand speech Slow growth in vocabulary and sentence structure

17. Articulation disorders n n Etiologies Damage to nerve pathways from brain to muscles in larynx, mouth or lips Delayed development from: – –hearing problems – –slow maturation of nervous system n n Recognition Speech slurred, indistinct, slow, or nasal

18. Voice production disorders Etiologies Disorder affecting vocal cord closure Hormonal or psychiatric disturbance Severe hearing loss

19. Voice production disorders n n Recognition Hoarseness Harshness Inappropriate pitch Abnormal nasal resonance

20. Fluency disorders n n Etiology Not fully understood n n Recognition Stuttering

21. Accommodations n n Allow patient time to respond n n Provide aids when available

22. Obesity

23. Etiologies n n Caloric intake > Calories burned n n Low basal metabolic rate Genetic predisposition

24. Accommodations n n Appropriately-sized diagnostic devices n n Maintain professionalism n n Additional assistance for lifting, moving

25. Paraplegia/ Quadriplegia

26. Description n n Paraplegia Weakness or paralysis of both legs n n Quadriplegia Paralysis of all extremities and trunk

27. Accommodations n n Airway/ventilation management n n Patients with halo traction device n n Ostomies: Trachea Bladder Colon n n May require additional assistance/ equipment

28. Mental illness

29. Description n n Any form of psychiatric disorder

30. Etiologies n n Psychoses Patient perceptions of reality radically different n n Neuroses Patient perceives reality normally but reacts to it inappropriately

31. Recognition n n Behavior not always affected n n May present with signs and symptoms consistent with underlying illness

32. Accommodations n n Don't be afraid to ask about History of mental illness Prescribed medications Whether patient is taking medications as prescribed Concomitant ingestion of alcohol, other drugs

33. Accommodations n n Solicit permission before beginning assessment n n Treat as patient that does not have mental illness, unless call is related specifically to the mental illness

34. Developmental disabilities n n Impaired or insufficient development of the brain n n Causes an inability to learn at a usual rate

35. Down's syndrome

36. Etiology n n Chromosomal abnormality (trisomy -21) resulting in: Mild to severe mental retardation Characteristic physical appearance

37. Recognition n n Eyes slope up at outer corners; folds of skin on either side of nose cover the inner corners of eye n n Small face, features n n Large, protruding tongue n n Flattening of back of head n n Hands short, broad

38. Accommodations n n IQ varies from 30-80 n n Approximately 25% have a heart defect at birth n n Articulation of C-1 on C-2 may be unstable

39. Emotional impairments n n Etiologies Neurasthenia Anxiety neurosis Compulsion neurosis Hysteria

40. Arthritis

41. Description n n Inflammation of joint n n Characterized by: Pain Stiffness Swelling Redness

42. Types/etiologies n n Osteoarthritis n n Rheumatoid arthritis n n Uremic arthritis (gout)

43. Accommodations Decreased range of motion/ mobility may limit physical exam n n Limited mobility n n Make equipment fit patient, not vice- versa n n Pad all voids n n Elicit current medications

44. Cerebral palsy n n Description Non-progressive disorder of movement and posture Caused by injury to brain during its early development A symptom complex rather than a specific disease

45. Types n n Spastic (70% of cases) Upper motor neuron involvement Abnormal stiffness and contraction of groups of muscles – –Hemiplegia – –Paraplegia – –Quadraplegia – –Diplegia (intermediate state between para- quadraplegia)

46. Types n n Athetoid or dyskinetic (20%) Basal ganglia involvement Involuntary, writhing movements of: – –Extremities (athetoid) – –Proximal limbs and trunk (dyskinetic) Movements increase with emotional tension; disappear during sleep

47. Types n n Ataxic (10%) Cerebellar involvement Loss of coordination and balance Unsteadiness Wide-based gait Difficulty with rapid or fine movements

48. Etiologies n n Prepartum Cerebral hypoxia Maternal infection Kernicterus (liver failure) n n Postpartum Encephalitis Meningitis Head injury

49. Accommodations n n 75% mentally retarded n n 25% have seizures n n Many with athetoid and diplegic cerebral palsy are highly intelligent

50. Accommodations n n May require additional resources to facilitate transport May need suctioning, due to increased oral secretions n n If contractures present: Pad appropriately Do not force extremities to move

51. Cystic fibrosis

52. Description n n Inherited metabolic disease of exocrine glands and eccrine sweat glands n n Primarily affects digestive, respiratory systems n n Begins in infancy

53. Etiology n n Autosomal recessive gene n n Both parents must be carriers n n Incidence Caucasians--1:2000 Blacks--1:17,000 Orientals--very rare

54. Pathophysiology n n Obstruction of pancreatic, intestinal gland, bile ducts n n Over-secretion by airway mucus glands n n Excess loss of sodium chloride in sweat

55. Recognition n n History n n Airway obstruction, chronic cough Recurrent respiratory infections May be oxygen-dependent n n Frequent, foul-smelling stools n n Salty taste on skin n n Intolerance of hot environments

56. Accommodation n n May require respiratory support, suctioning, oxygen

57. Multiple sclerosis

58. Description n n Progressive disease of CNS n n Scattered patches of myelin in the brain and spinal cord are destroyed n n Results in multiple, varied neurologic symptoms, signs

59. Etiologies n n Unknown n n Probably autoimmune disease n n Genetic factors influence susceptibility n n Women affected more often than men

60. Recognition n n Painful muscle spasms n n Recurrent urinary tract infections n n Constipation n n Skin ulcerations n n Changes of mood, from euphoria to depression

61. Recognition n n If brain affected: Fatigue Vertigo Clumsiness Muscle weakness Slurred speech Ataxia Blurred or double vision Numbness, weakness or pain in face

62. Recognition n n If spinal cord affected Tingling, numbness, or feeling of constriction in any part of the body Extremities may feel heavy and become weak Spasticity

63. Accommodation n n Possible respiratory support n n Patient should not be expected to ambulate

64. Muscular dystrophy

65. Description n n Inherited muscle disorder n n Slow progressive degeneration of muscle fibers n n Unknown Cause

66. Recognition n n History n n Little or no movement of muscle groups

67. Accommodation n n Possible respiratory suport n n Patient should not be expected to ambulate

68. Poliomyelitis

69. Description n n Caused by virus n n Usually results in mild illness n n In more serious cases, attacks the CNS May result in paralysis or death

70. Recognition n n History Paralysis

71. Accommodations n n If lower extremities paralyzed, patient may require catheterization n n If respiratory paralysis, patient may require tracheostomy n n Patient should not be expected to ambulate

72. Spina bifida

73. Description n n Congenital defect n n Part of one or more vertebrae fails to develop n n Leaves portion of spinal cord exposed

74. Etiology n n Unknown n n May be related to dietary deficiencies during pregnancy (folic acid)

75. Recognition n n History n n Often associated with: CNS infections Obstructive uropathies Hip joint dislocations

76. Accommodations n n Patient should not be expected to ambulate, although most can

77. Myasthenia gravis

78. Description n n Autoimmune disorder n n Results in acetylcholine production, binding at neuromuscular junction n n Muscles become weak and tire easily n n Eyes, face, throat, and extremity muscles most commonly affected

79. Recognition n n Drooping eyelids, double vision n n Difficulty speaking n n Chewing, swallowing may be difficult n n Extremity movement may be difficult n n Respiratory muscles may be weak

80. Accommodations n n Airway control n n Assisted ventilation n n Patient may be unable to ambulate

81. Culturally diverse patients

82. Variables n n Ethnicity n n Religion n n Language n n Gender n n Homelessness

83. Accommodations n n Obtain permission to treat when possible n n Beliefs may conflict with learned medical practice n n Attempt to recruit an interpreter n n Early notification of receiving facility

84. Terminally Ill Patients n n Hospice Care n n Advance directives, DNR

85. Financial Challenges n n Apprehensive about seeking medical care