Curriculum Update: Patients With Special Challenges and Interventions for Patients with Chronic Care

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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
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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

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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

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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

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Patients With Special Challenges - Visual
Impairment

• Etiologies
• Injury
• Disease
• Degeneration of eyeball, optic
  nerve or nerve pathways
• Congenital
• Infection (C.M.V.)

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

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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

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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

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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

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Utilizing Translation Line
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Patients With Special Challenges -Obesity

• Definition
• body weight 20 over the average weight of people
  same size, gender, age
• gt58 million Americans are obese
• 2nd leading cause of preventable death
• Etiologies
• Caloric intake exceeds calories burned
• Low basal metabolic rate
• Genetic predisposition

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Obesity Risk Factors

• Hypertension
• Stroke
• Heart disease
• Diabetes
• Some cancers
• Kidney failure

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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

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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

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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

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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

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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

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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

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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

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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

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Assessment/Management Accommodations - Mental
Illness

• Solicit permission before beginning care
• Gain rapport/trust but your safety is first
• Dont make promises you cant keep
• Dont 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

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Patients With Special Challenges - Downs 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

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Assessment/Management Accommodations - Downs
Syndrome

• Congenital heart, intestinal, hearing defects
• Limited learning capability
• Generally affectionate and friendly
• Utilize patience with assessment
• Explain procedures before beginning task

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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

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Emotional or Mental Impairment

• IQ Mild impairment 55-70
• Moderate impairment 40-54
• Severe impairment 25-39
• Profound impairment lt 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

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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

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Etiologies Emotionally/Mentally Impaired contd

• Poverty/cultural deprivation
• Malnutrition
• Disease-producing conditions (lack of
  cleanliness)
• Inadequate medical care
• Environmental health hazards
• Lack of stimulation

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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 UTIs

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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

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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

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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

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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

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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)

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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

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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

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Patients With Special Challenges

• Financial Challenges
• A patients 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

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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

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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

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Interventions for the Specially Challenged and
Chronic Care Patient
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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

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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
• 
  

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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)

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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

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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
• 
  

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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

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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

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Home Care Airway Adjuncts

• Oxygen delivery devices
• CPAP machine
  (mask and nasal)
• BiPAP machine
• Tracheotomies
• Home ventilators
• Peak flow machine

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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

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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
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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

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Assessing Complications of the Airway

• Evaluate
• Respiratory effort
• Tidal volume
• Peak flow
• Oxygen saturation
• Breath sounds
• Compare values based on the patients normal or
  baseline levels

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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
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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

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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

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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

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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

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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

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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, doctors
  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

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Patients with Special Challenges and Chronic Care
Needs
Questions ??