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Condell Medical Center EMS System

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1 Condell Medical Center EMS System
Curriculum Update: Patients With Special Challenges and Interventions for Patients with Chronic Care Needs Condell Medical Center EMS System August 2006 Site Code # E1206 Revised by: Sharon Hopkins, RN, BSN EMS Educator

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 Faulty transportation of sound from outer to the inner ear. Curable disease process. Infections like otitis media and Injury like barotrauma may cause this problem.

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

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 80% of hearing loss is related to the loss of High-pitched sounds. Use low-pitched sounds is more Effective. Specialized assistive devices that may be used by the hearing impaired patient include amplified or typed message Telephones, low frequency or flashing doorbells, closed-caption TV decoders, flashing alarm clocks and fire alarms

5 Patients With Special Challenges - Visual Impairment
Etiologies Injury Disease Degeneration of eyeball, optic nerve or nerve pathways Congenital Infection (C.M.V.) Visual impairment is any condition that obstructs the passage of Light from the retina. May be present at birth or congenital. Congenital etiologies are: cataracts, diabetes, hypertension. Vitamin A deficiency in children in developing countries.

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

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 patient’s special needs Carefully lead patient when ambulatory patient holds your arm call out obstructions, steps and turns ahead of time

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 Patients frequently demonstrate aphasia with slowness to Understand speech and problems with vocabulary and Sentence structure. Delayed development of language May result from hearing loss, lack of stimulation, or emotional Disturbance.

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 Characterized by hoarseness, harshness, inappropriate Pitch, abnormal nasal resonance.

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

11 Utilizing Translation Line

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

13 Obesity Risk Factors Hypertension Stroke Heart disease Diabetes
Some cancers Kidney failure

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

15 Breathing Considerations in Obesity
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

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

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

18 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

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

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

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 Psychoses- may be related to biochemical disease that alters brain function. Such as Schizophrenia, bipolar disorder (manic-depressive disorder), organic brain disease. Neuroses- don’t limit social or work responsibilities. Fluctuate with intensity and stress Level. Such as depression, phobias, obsessive-compulsive disorders

22 Assessment/Management Accommodations - Mental Illness
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 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

23 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

24 Assessment/Management Accommodations - Down’s Syndrome
Congenital heart, intestinal, hearing defects Limited learning capability Generally affectionate and friendly Utilize patience with assessment Explain procedures before beginning task

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

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

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

28 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

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

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

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

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

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

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

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 Prepartum cerebral palsy results from cerebral hypoxia and maternal infection. Postpartum results from encephalitis, meningitis and head Injury. Although no cure, many are of high intelligence and have Relative independence and normal life expectancy.

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

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

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

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)

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

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 UTI’s

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

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

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

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

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 have reduced incidences In USA polio virus now injected and not oral form (virus shed thru GI system when given orally)

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

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

49 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

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

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

52 Interventions for the Specially Challenged and Chronic Care Patient

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

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

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)

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

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

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

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

60 Home Care Airway Adjuncts
Oxygen delivery devices CPAP machine (mask and nasal) BiPAP machine Tracheotomies Home ventilators Peak flow machine

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

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

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

64 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

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

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

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

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

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

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

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, 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

72 Patients with Special Challenges and Chronic Care Needs
Questions ??

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