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The Challenged Patient Ray Taylor Valencia Community College Department of Emergency Medical Services Topics Physical Challenges Developmental Disabilities Pathological Challenges Other Challenges Introduction Challenged Patients – Hearing – Visual – Speech – Obesity – Paralysis – Mental and physical impairments – Arthritis – Cancer – Neuromuscular Hearing Impairments Types – Conductive deafness – Sensorineural deafness Conductive Deafness Blockage of the transmission of sound waves through the external ear canal to the middle or inner ear Etiologies (Curable) – Infection – Injury – Earwax Sensorineural Deafness Deafness caused by the inablility of nerve impulses to reach the auditory center of the brain because of nerve damage to either the inner ear or to the brain Etiologies (Many incurable) – – – – – – – – Congenital Birth injury Disease Medication induced Viral infection Tumor Prolonged exposure to loud noise Aging Recognizing Deafness Asking questions repeatedly Misunderstood questions or inappropriate responses Presence of a hearing aid Sign language or gestures Hearing aids come in various shapes and sizes. Figure 5-1 Accommodations for Deaf Patients Address patient face to face. Speak slowly in a normal voice. – Do not shout – 80% of hearing loss is related to the loss of high pitched sounds – Use low pitched sounds directly into ear canal Reduce background noise as much as possible. Help find or adjust hearing aids. Use pen and paper. Utilize an interpreter. Use of picture that illustrate basic need/procedures Visual Impairments Causes Disease Congenital conditions Infection Degeneration of eyeball, optic nerve or nerve pathways Individuals who are visually impaired can maintain active, independent lives. Figure 5-2 Accommodations Retrieve visual aids Describe everything that you’re going to do Provide sensory information If ambulatory, guide by leading, not by pushing Allow leader dogs to accompany patient – Do not pet or handle dog while in harness Speech Impairments Types of Speech Impairments Language disorders Articulation disorders Voice production disorders Fluency disorders Etiology of Speech Disorders Language disorders – – – – – – – Stroke Head injury Brain tumor Delayed development Hearing loss Lack of stimulation Emotional disturbance Etiology of Speech Disorders Articulation disorders – From damage to nerve pathways passing from brain to muscles in larynx, mouth or lips – Delayed development from hearing problems, slow maturation of nervous system Etiology of Speech Disorders Voice production disorders – Disorder affecting closure of vocal cords – Hormonal or psychiatric disturbance Fluency disorders – Not fully understood Recognition Language disorders – Slowness to understand speech – Slow growth in vocabulary and sentence structure Articulation disorders – Speech can be slurred, indistinct, slow, or nasal Recognition Voice production disorders – – – – Hoarseness Harshness Inappropriate pitch Abnormal nasal resonance Fluency disorders – Stuttering Accommodations for Speech Impairments Never assume the person lacks intelligence. Form questions that require short, direct answers. Never pretend to understand when you don’t. Let the patient write answers to questions. Obesity 40% of people in the US are obese. Excess weight can exacerbate the complaint for which you were called. Obesity can lead to many serious medical conditions Obesity Etiologies – When a person has an abnormal amount of body fat » 20-30% heavier than normal weight – Person’s caloric intake is higher than the amount of calories required to meet his energy needs – Genetic factors – Low basal metab Accommodations for Obese Patients Don’t dismiss signs or symptoms, such as shortness of breath, as being a result of obesity. Adipose tissue presents an obstruction—EKG electrodes may need to be placed on the arms and legs. Do not compromise your health or safety—ask for assistance when lifting or moving a patient. Use appropriately sized diagnostic devices Paralysis Paraplegia – Weakness or paralysis of both legs Quadriplegia – Paralysis of all four extremities and trunk Paralysis The patient may have a home ventilator; be sure to keep the airway clear and patent. If the patient is in halo traction, be sure to stabilize the traction before transport. Be aware of other assistive devices— colostomy, canes, wheelchairs, etc. Mental Challenges Mental illness – Any form of psychiatric disorder – Etiologies » Psychosis Caused by complex biochemical brain disease » Neuroses Disease related to personality – Recognition » Behavior may be unaffected » May present with signs and symptoms consistent with illness Accommodations Obtaining a history – Don’t be afraid to ask about » History of mental illness » Prescribed medications » Compliance with medications » Concomitant ingestion of alcohol, other drugs Assessment and Management Assessment – Be sure to solicit permission before beginning Management – Treat as you would any patient that does not have a mental illness, unless call is related specifically to the mental illness » Patients with mental illness also experience myocardial infarctions, hypoglycemic episodes Developmental Disabilities Developmental Disabilities Description – Impaired/ insufficient development of the brain, causing an inability to learn at the usual rate Recognition – History Accommodations – – – – Obtaining a history Assessment Management Transport Developmentally disabled people may have trouble communicating, but can often still understand what you say. Figure 5-3 Remember that a person with a developmental disability can recognize body language, tone, and disrespect just like anyone else. Treat them as you would any other patient. Developmental Disabilities Down Syndrome – A chromosomal abnormality resulting in mild to severe mental retardation, and a characteristic physical appearance Fetal Alcohol Syndrome (FAS) – Mother with persistent alcoholism during gestation » Shortly after birth infants experience alcohol » Deficient growth and mental capacity Recognition of Down Syndrome Eyes slope up at outer corners; folds of skin on either side of nose cover the inner corners or eye Small face and features Large and protruding tongue Flattening on back of the head Hands short and broad Recognition of Fetal Alcohol Syndrome Small head with multiple facial abnormalities – Small eyes with short slits – Wide, flat nasal bridge – Midface that lacks a groove between the lip and nose – Small jaw Pathological Challenges Arthritis Cancer Cerebral Palsy Cystic Fibrosis Multiple Sclerosis Muscular Dystrophy Poliomyelitis Previous head injury Spina Bifida Myasthenia Gravis Arthritis Inflammation of a joint; characterized by pain, stiffness, swelling, redness Accommodations – Decreased range of motion/mobility may limit physical exam – Be sure to solicit current medications before considering the administration of medications Management – Limited ability to be mobile – Make equipment fit patient, not vice-versa, pad all voids Rheumatoid arthritis causes joints to become painful and deformed. Cancer Primary site of origin of the cancer cells determines the type of cancer – Carcinoma – Sarcoma Treatments for the disease do tend to produce telltale signs – – – – Alopecia (hair loss) Anorexia Radiation tattoos Physical changes Cancer Management – Patient’s risk for infection » Chemotherapy leaves patient neutropenic – Veins may have become scarred – Use of med ports » Requires specialized training Cerebral Palsy Nonprogressive disorders of movement and posture Types – Spastic » Abnormal stiffness and contraction of groups of muscles – Athetosis » Involuntary, writhing movements – Ataxia » Loss of coordination and balance Cerebral Palsy Etiologies – Most occur before birth – Prepartum » Cerebral hypoxia » Maternal infection – Postpartum » Encephalitis » Meningitis » Head Injury Recognition Spastic: muscles of one or more extremities are permanently contracted Athetoid: involuntary writhing movement Quadriplegia Mental retardation in about 75% of all people with with CP Many people with athetoid and diplegic CP are highly intelligent Cystic Fibrosis (Mucoviscidosis) An inherited metabolic disease of the lungs and digestive system, manifesting itself in childhood – A defective, recessive gene Recognition – – – – History Patient may be oxygen dependent Salty taste in mouth Productive cough Management – May require respiratory support, suctioning, oxygen Multiple Sclerosis A progressive autoimmune disease of the CNS, whereby scattered patches of myelin in the brain and spinal cord are destroyed Unknown etiology Recognition – – – – – Fatigue, vertigo Clumsiness, muscle weakness Slurred speech, ataxia Blurred or double vision Numbness, weakness or pain in face Multiple Sclerosis Spinal cord affected – Tingling, numbness, or feeling of constriction in any part of the body – Extremities may feel heavy and become weak – Spasticity may be present Multiple Sclerosis Accommodations – Recognize characteristic presentation – May be accompanied by » Painful muscle spasms » UTI » Constipation » Skin ulcerations » Changes in mood, from euphoria to depression Muscular Dystrophy An inherited muscle disorder of unknown cause in which there is slow but progressive degeneration of muscle fibers Little or no movement of muscle groups Management: possible respiratory support, patient should not be expected to ambulate Patients with multiple sclerosis and muscular dystrophy may use a cane to aid ambulation. Be sure to take such devices with you on the ambulance. Figure 5-6 Poliomyelitis Caused by a virus, which usually results in a mild illness In more serious cases, it attacks the CNS: may result in paralysis or death Patients with severe polio may present with paralysis (including respiratory) Poliomyelitis Accommodations – If lower extremities are paralyzed, patient may require catherterization – If respiratory paralysis, patient may require tracheostomy – Patient should not be expected to ambulate Patients with Previous Head Injury Recognition – Physical appearance may be uncharacteristic – Speech and mobility may be affected – Short term memory loss Spinal Bifida A congenital defect in which part of one or more vertebrae fails to develop, leaving a portion of the spinal cord exposed Unknown etiology Recognition: History Transport: patient should not be expected to ambulate Myasthenia Gravis A disorder in which muscles become weak and tire easily Eyes, face, throat, and extremity muscles most commonly affected Etiology: Autoimmune disorder of unknown etiology Recognition – – – – – Drooping eyelids, double vision Difficulty speaking Chewing, swallowing may be difficult Movement of extremities may be difficult Respiratory muscles may be weakened Other Challenges Culturally diverse patients Terminally ill patients Patients with communicable diseases Financial challenges United States society is becoming diverse, with the largest number of immigrants coming from Asia and Latin America. Figure 5-7 If a patient refuses care because of cultural or religious beliefs, be sure to have the patient sign a Refusal of Treatment and Transportation form. Figure 5-8 Financial Challenges Treat the patient, not the financial condition of the patient. Homeless people sometimes refuse care, thinking they cannot afford to pay the medical bills. Become familiar with public hospitals and clinics that provide services to the needy. Figure 5-9 Summary Physical Challenges Development Disabilities Pathological Challenges Other Challenges