Chapter 36 Patients With Special Challenges

Chapt 36 Patients With Special Challenges -Some people living at home depend upon: 1. Mechanical ventilation 2. Intravenous pumps 3. Other devices Intellectual Disability -Developmental disability 1. Refers to insufficient development of the brain, resulting in some level of dysfunction or impairment. 2. Can include intellectual, hearing, or vision impairments that surface during infanthood or childhood. a. Intellectual disability results in the inability to learn and socially adapt at a normal developmental rate. 3. Characteristics of a patient with slight intellectual impairment: a. May appear slow to understand or have a limited vocabulary b. May behave immaturely compared to their peers c. If severely disabled, may not have the ability to care for themselves, communicate, understand, or respond to surroundings 4. Rely on patients and family members for information. 5. Patient may have difficulty adjusting to change or a break in routine. a. Make every effort to respect the patient’s wishes and concerns. 6. Patients with intellectual disabilities are susceptible to the same diseases as other patients. Autism Spectrum Disorder 1. Developmental disorder characterized by impairment of social interaction a. Severe behavioral problems b. Repetitive motor activities c. Impairment in verbal and nonverbal skills d. May be hyper- or hyposensitive to sensory stimuli e. May show their pain in unusual ways, such as humming, singing, and removing clothing 3. Patients have difficulty using or understanding nonverbal means of communicating a. Frequently have difficulty making eye-to-eye contact b. Do best with simple, one-step directions c. Tend to have trouble answering open-ended questions d. May to talk in robotic or monotone speech patterns 4. It affects males five times greater than females. Down syndrome 1. Characterized by a genetic chromosomal defect that can occur during fetal development, resulting in mild to severe intellectual impairment 2. Physical abnormalities a. Round head with a flat occiput b. Enlarged, protruding tongue c. Slanted, wide-set eyes & folded skin on either side of nose, covering the inner corners of eye d. Short, wide hands e. Small face and features 3. Increased risk for medical complications a. As many as 40% may have heart conditions and hearing and vision problems. 4. Intubation may be difficult due to large tongues and small oral and nasal cavities. 7. In approximately 15% of people with Down syndrome, the atlantoaxial joint, where the first two vertebrae meet, is unstable. a. Increased risk of complications such as spinal cord injury when they experience trauma Patient interaction 1. It is normal to feel somewhat uncomfortable when initiating contact with a developmentally disabled patient. 2. Approach the patient in a calm, friendly manner, watching for signs of increased anxiety or fear. 3. Have the members of your team hold back slightly until you can establish a rapport with the patient. 4. Introduce the team members and explain what they are going to do. 5. Move slowly but deliberately, explaining beforehand what you are going to do. 7. Watch carefully for signs of fear or reluctance from the patient, and do your best to soothe the patient’s anxiety and discomfort. 8. By initially establishing trust and communication, you will have a much better chance for a successful outcome. Brain injury 1. Patients with a prior brain injury may be difficult to assess and treat. 2. Take the time to speak with the patient and family to establish what is considered normal for the pt. 3. Treat the patient with respect, use his or her name, explain procedures, and reassure the patient throughout the process. Sensory Disabilities -Visual Impairment 1. Possible causes 2. Degree of visual impairment may range from partial to total. a. Some patients lose peripheral or central vision. b. Some can distinguish light from dark or discern general shapes. 3. Visual impairments may be difficult to recognize. 4. Patient interaction a. Make yourself known when you enter the room. c. Retrieve any visual aids, give them to your patient to make the interaction more comfortable. d. A visually impaired patient may feel vulnerable, especially during the chaos of a crash scene. e. Tell the patient what is happening, identify noises, and describe the situation and surroundings, especially if you must move the patient. Hearing Impairment 1. Impairment may range from a slight hearing loss to total deafness. a. Many older people will have some degree of hearing loss. 2. Most common forms of hearing loss 3. Clues that a person could be hearing impaired a. Presence of hearing aids b. Poor pronunciation of words c. Failure to respond to your presence or questions Hearing aids 1. Device that makes sound louder a. Behind-the-ear type b. Conventional body type c. In-the-canal and completely in-the-canal type d. In-the-ear type e. Implantable options are also available. 2. The device should fit snugly. 3. If whistling occurs, the hearing aid may not be in far enough. Physical Disabilities -Cerebral palsy 1. Group of disorders characterized by poorly controlled body movement 2. Range of mild to severe symptoms 3. Important considerations a. Observe airway closely b. Do not assume that patients have an intellectual disability. c. Limbs are often underdeveloped and are prone to injury. d. Pts who have the ability to walk may have an ataxic or unsteady gait and are prone to falls. -Spina bifida 1. Birth defect caused by incomplete closure of spinal column during embryonic or fetal development 2. Spinal cord is exposed. 3. Opening can be closed surgically, but often leaves spinal and neurologic damage. 4. Associated conditions a. Hydrocephalus b. Partial or full paralysis of the lower extremities c. Loss of bowel and bladder control -Paralysis 1. Inability to voluntarily move one or more body parts 2. Possible causes 3. Patient may have normal sensation or hyperesthesia (increased sensitivity). 4. Facial paralysis may also cause communication challenges 5. Diaphragm may not function correctly, requiring the use of a ventilator. 6. Patients may have specialized equipment a. Urinary catheters, Tracheotomy tube, Colostomy tube, Feeding tubes 8. Ask patients or caregivers how to best move them before you transport them. -Bariatric Patients 1. The result of an imbalance between calories consumed and calories used 2. Causes of obesity are not fully understood. 3. May be attributed to a low metabolic rate or genetic predisposition -Severe or morbid obesity 1. Term obese used when someone is 30% or more over ideal body weight 2. Severe obesity is when a person is 2–3 times over the ideal weight. 3. Quality of life may be negatively affected. 4. Associated health problems Patients With Medical Technology Assistance -Tracheostomy tubes 1. Tracheal stoma provides a path between the surface of the neck and the trachea and is kept open by a plastic tracheostomy tube 2. Can be temporary or permanent 3. For patients who: a. Depend on home automatic ventilators b. Have chronic pulmonary medical conditions 4. Because it is foreign to respiratory tract, the body reacts by building up secretions in or around the tube. 5. Tubes are prone to becoming obstructed by mucous plugs or foreign bodies. a. DOPE mnemonic helps to recognize cause of obstruction 6. Common problems 7. Management Mechanical ventilators 1. Used when patients cannot breathe without assistance 2. If the ventilator malfunctions: a. Remove the patient from the ventilator. b. Apply a tracheostomy collar. c. Patients require assisted ventilation throughout transport. 3. The patient’s caregivers will know how the mechanical ventilator works. Apnea monitors 1. Used for infants who: a. Are premature b. Have severe gastroesophageal reflux that causes choking episodes c. Have a family history of sudden infant death syndrome d. Have experienced an apparent life-threatening event 2. Used for 2 weeks to 2 months after birth to monitor the respiratory system 3. Monitor sounds an alarm if the infant experiences bradycardia or apnea. 4. If possible, bring the apnea monitor to the receiving hospital with the patient. Internal cardiac pacemakers 1. Device implanted under the patient’s skin to regulate the heart rate 2. Pacemaker may also include an automated implanted cardioverter defibrillator (AICD) to monitor heart rhythm. 3. Never place defibrillator paddles or pacing patches directly over the implanted device. 4. Gather information about the cardiac pacemaker during history taking. Left ventricular assist devices 1. Medical device that takes over the function of one or both heart ventricles 2. Typically used as a bridge to heart transplantation while a donor heart is being located, or may be a permanent solution for patients who do not qualify for a transplant. 3. May be difficult to palpate a pulse in patients who use an LVAD (Assess perfusion) 4. Care External defibrillator vest 1. A vest with built-in monitoring electrodes and defibrillation pads, which is worn by the patient under his or her clothing. 2. Attached to a monitor that provides alerts and voice prompts when it recognizes a dangerous rhythm and before it delivers a shock. 3. If the patient is in cardiac arrest, the vest should remain in place while you perform CPR unless it interferes with compressions. Central venous catheter 1. A catheter that has its tip placed in the vena cava to provide venous access 2. Used for many types of home care patients receiving: a. Chemotherapy, Total parenteral nutrition (TPN), Hemodialysis b. Long-term antibiotic drug therapy or pain management Gastrostomy tubes 1. Sometimes referred to as gastric tubes or G-tubes 2. Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth a. May be inserted through nose or mouth into stomach (using a nasogastric or orogastric tube) b. May be placed surgically directly into the stomach through the abdominal wall 3. May become dislodged during the patient’s normal daily activity a. Immediately stop the flow of any fluids. b. Assess for signs or symptoms of bleeding into the stomach. 4. Patients may be at increased risk of aspiration. a. Always have suction readily available. b. Patients with difficulty breathing should be transported while sitting or lying on their right side with the head elevated 30°. Shunts 1. For patients with chronic neurologic conditions 2. Tubes that drain excess cerebrospinal fluid 3. Types a. Ventricular peritoneum shunt—drains excess CSF from the ventricles of the brain into the peritoneum of the abdomen b. Ventricular atrium shunt—drains excess CSF from the ventricles of the brain into the right atrium of the heart 4. During assessment, you will likely feel the fluid reservoir beneath the skin on the side of the head, behind the ear. 5. Blocked or infected shunt a. Changes in mental status and respiratory arrest may occur. b. Infections may occur within the first 2 months after insertion. Vagus nerve stimulators 1. Treatment used for seizures that are not controlled with medication 2. Stimulate the vagus nerve to keep seizure activity from occurring 3. Located under the patient’s skin 4. About the size of a silver dollar Colostomies, ileostomies, and urostomies 1. Colostomy or ileostomy is a surgical procedure that creates an opening between the small or large intestine and the surface of the body. a. Allows for elimination of waste products into an external bag or pouch, which is emptied or changed frequently b. Assess for signs and symptoms of dehydration if the patient has been complaining of diarrhea or vomiting 2. Urostomy is a surgical procedure that connects the urinary system to the surface of the skin. a. Allows urine to drain through a stoma in the abdominal wall instead of through the urethra. 3. Contact medical control/follow local protocols for care of pt w/ colostomy, ileostomy, or urostomy bag Patient Assessment Guidelines -Interaction with the caregiver of an adult or child with special needs is an important part of the patient assessment process. 1. They have become experts on caring for the patient. -Determine the patient’s normal baseline status before assessment→ Ask, “What is different today?” Home Care -Home care occurs within a patient’s home environment. -Represents a spectrum of special health care populations 1. Infants, Older adults, Patients with chronic illnesses, Patients with developmental disability -Obtain baseline health status and history from the home care provider. Hospice Care and Terminally Ill Patients -Terminally ill patients may receive hospice care at a hospice facility or at home with diseases such as: 1. Cancer 2. Heart and lung failure 3. End-stage Alzheimer disease 4. AIDS -Most patients have completed a do not resuscitate (DNR) order Comfort care 1. Palliative care (pain medication) 2. Improves the patient’s quality of life before the patient dies and allows the patient to be with family and friends -Follow your local protocols, the patient’s wishes, or legal documents such as a DNR order. Poverty and Homelessness -People who live in poverty are unable to provide for all of their basic needs. 1. Housing 2. Food 3. Child care 4. Health insurance 5. Medication Homeless population includes: 1. People with mental illness or prior brain trauma 2. Victims of domestic violence 3. Persons with addiction disorders 4. Impoverished families