1. Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display. 46-1 Chapter 46 Patients with Special Challenges

2. 46-2 Objectives

3. Child Abuse and Neglect 46-3

4. Child Maltreatment 46-4

5. Physical Abuse Acts that caused or could have caused physical injury to the child –Hitting –Kicking –Shaking –Burning –Other acts of harm 46-5

6. Possible Abuse Consider the possibility of physical abuse when the child: –Has unexplained burns, bites, bruises, etc. –Has fading bruises or other marks after an absence from school –Seems frightened of the caregiver –Shrinks at the approach of adults –Reports injury by an adult 46-6

7. Medical Conditions Impetigo 46-7 Mongolian spots

8. Cultural Considerations 46-8

9. Possible Abuse Consider the possibility of physical abuse when the parent or other adult caregiver offers conflicting, unconvincing, or no explanation for the child’s injury 46-9

10. Sexual Abuse Inappropriate adolescent or adult sexual behavior with a child Includes fondling, rape, and exposing a child to other sexual activities 46-10

11. Emotional Abuse Refers to behaviors that harm a child’s self- worth or emotional well-being Examples –Name calling –Shaming –Rejection –Withholding love –Threatening 46-11

12. Neglect Failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm or potential harm Types: –Medical –Physical –Educational –Emotional 46-12

13. Medical Neglect Failure of the caregiver to provide for the appropriate healthcare of the child although they are financially able to do so 46-13

14. Signs of Neglect 46-14

15. Care of Abuse Provide emergency care for the child as needed Do not accuse in the field Reporting is required by state law Remain objective Report what you see and what you hear –Do not comment on what you think 46-15

16. Care of Abuse Show a professional and caring attitude After the call, assess your own emotional needs 46-16

17. Elder Abuse Elder abuse is any physical, sexual, or emotional, abuse committed against an older adult. Categories of elder abuse –Domestic elder abuse –Institutional elder abuse –Self-neglect or self-abuse 46-17

18. Elder Abuse Physical abuse –Inappropriate use of drugs and physical restraints –Force-feeding –Physical punishment of any kind 46-18

19. Elder Abuse Sexual abuse –Bruises around the breasts or genital area –Unexplained vaginal or anal bleeding –Torn, stained, or bloody underclothing –Older adult’s report of being sexually assaulted or raped 46-19

20. Elder Abuse Emotional abuse –Insults –Threats –Intimidation –Harassment –Treating the older adult like an infant –Isolating the older adult from his family, friends, or regular activities –Giving older adult the “silent treatment” 46-20

21. Elder Abuse Neglect : Failure to provide necessities –Food –Water –Clothing –Shelter –Personal hygiene –Medicine –Comfort –Personal safety –Necessary home care services 46-21

22. Examples of Older Adult Neglect Dehydration Malnutrition Untreated bedsores Poor personal hygiene Unattended or untreated health problems Hazardous or unsafe living conditions / arrangements Unsanitary and unclean living conditions Older adult’s report of being mistreated 46-22

23. Elder Abuse Provide emergency care for the patient as needed Do not accuse in the field Reporting is usually required by state law Remain objective Report what you see and what you hear –Do not comment on what you think 46-23

24. Homelessness Two main reasons for the rise in homelessness over the past 20-25 years –A growing shortage of affordable rental housing –An increase in poverty Homelessness and poverty often go hand in hand 46-24

25. Factors that Contribute to Homelessness Decreasing work opportunities Stagnant or falling incomes Less secure jobs that offer fewer benefits Lack of affordable health care Domestic violence Mental illness Racial discrimination Addiction disorders, such as drugs and alcohol 46-25

26. Common Illnesses among the Homeless Upper respiratory tract infections Trauma Female genitourinary problems Hypertension Skin and ear disorders Gastrointestinal diseases Peripheral vascular disease Musculoskeletal problems Dental problems Vision problems 46-26

27. Homelessness Personal protective equipment Treat the patient with respect Talk with your patient Listen without making a moral judgment Document objectively 46-27

28. Bariatric Patients 46-28

29. Bariatric Patients Bariatrics –The branch of medicine that deals with the causes, prevention, and treatment of obesity and weight-related health problems Increased risk for diabetes, hypertension, heart disease, and stroke 46-29

30. Bariatric Patients Proper positioning and handling of the bariatric patient is important. If conscious and hypotension is not present, allow patient to assume a position of comfort. 46-30

31. Bariatric Patients Know manufacturer’s weight limitations on EMS equipment –Backboards –Stair chairs –Stretchers Use bariatric unit, if available Request additional resources if necessary Unconventional methods of moving the patient may be necessary 46-31

32. Patients with Special Health Care Needs 46-32

33. Tracheostomy Tubes Possible complications –Obstruction of the tube –Dislodgment –Bleeding –Air leak –Infection 46-33

34. Emergency Care of Tracheostomy Tubes Request ALS personnel If the tube is dislodged, ventilate as needed with a bag-mask device If external bleeding is present, apply gentle direct pressure to the bleeding site Allow the patient to maintain a position of comfort 46-34

35. Home Mechanical Ventilators Mechanical ventilators are used to assist breathing Ventilator malfunction –Disconnect the patient from the ventilator –Request ALS personnel –Maintain an open airway –Provide positive-pressure ventilation with a bag-mask device 46-35

36. Apnea Monitors Strap worn around the chest –Sensors in the strap are connected to a monitor that has an alarm Monitor chest movement and hear rate Ensure an open airway If breathing is inadequate, provide positive- pressure ventilation Reassess as often as indicated 46-36

37. Central Lines Central line –IV line placed near the heart for long-term use Peripherally inserted central catheter –PICC line –Smaller than those routinely used for central lines Emergency care 46-37

38. Gastrostomy Tubes and Gastric Feeding Gastrostomy tube –Special catheter placed directly into the stomach for feeding “Feeding button” Emergency care 46-38

39. Shunts Hydrocephalus Ventricular shunt Blockage of the shunt produces signs and symptoms of increased intracranial pressure Emergency care 46-39

40. Hospice Care 46-40

41. Palliative Care Palliative care –Also called comfort care –Care provided to relieve symptoms of disease, rather than to cure the disease –Usually provided for patients with a terminal illness and their families 46-41

42. Hospice Care Hospice care –A program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying persons, their families, and other loved ones 46-42

43. Hospice Care Many hospice patients have do not resuscitate (DNR) orders Assess the patient Determine the existence of a valid DNR as a part of your patient assessment 46-43

44. Questions? 46-44