Vol.5-Ch.7 "The Challenged Patient"

Question 1

Describe deafness, and what are the 2 general types of deafness.

Answer 1

Deafness is the loss of ability to distinguish or hear sounds. It may be complete or partial, affect one or both ears, may have been since birth or developed.

There are two basic types, Conductive Deafness which has many forms and can be treated/cured especially if caught early; and there is Sensorineural Deafness which cannot be cured.

CONDUCTIVE DEAFNESS: Any condition that prevents soundwaves from being transmitted from the external ear to the middle or inner ear. It can be temporary OR permanent. Examples include:

• Common cause in kids is Otitis Media, an infection of the middle ear, often secondary to upper resp tract illnesses.
• Impacted Cerumen (often occurs with cotton swab cleaning which pushes ear wax further back and sets the stage for an ear infection)
• Airline flights
• Deep water dives or water in the ear
• Temp blockage from dust, hair spray, insects, ect
• Also hematomas or bone blockages from head trauma

SENSORINEURAL DEAFNESS: Inability of nerve impulses to reach the auditory center of the brain b/c of damage either to the inner ear or to the brain itself. This is usually a permanent condition. Examples include:

• Things that put kids at risk for this include: (most common) birth defects/injuries, asphyxia during neonatal period, ototoxic drugs such as lasix and gentamicin given to kids, or whos mothers contracted rubella (German measles) during first 3 months of pregnancy.
• Diseases such as bacterial meningitis, viral illnesses such as Labyrinthitis (inner ear infection)
• Ototoxic drugs such as aspirin (common aspirin toxicity symptom is tinnitus or ringing in the ears)
• Tumors, concussions, ear trauma, repeated loud noises
• Conditions normal to aging such as Presbycusis which is a progressive hearing loss that starts at 20 and gets worse after 65+

Question 2

What are some observations that may lead you to suspect a pt suffers deafness?

Answer 2

They may:

• ask you to repeat questions
• misunderstand answers to questions
• respond inapproiately (this may be confused with signs of a head injury)
• THE MOST OBVIOUS SIGN is a hearing aid
• have poor diction
• use hand gestures or sign language
• may ask to speak louder
• may face you so they can read your lips

Question 3

What are some accommodations you can consider for deaf pts?

Answer 3

• face them when talking to them so they can try to read your lips
• speak slowly and in a normal voice, do not yell or use exaggerated gestures
• since 80% of hearing loss is high pitched sounds try using a lower registered tone
• reduce background noise as much as possible
• you may have to help find or adjust a hearing aid, if one is not available you can try giving them a stethoscope and speaking into the bell
• USE PEN AND PAPER
• Use sign language if you know it or find an interpreter if available

Question 4

What are some causes of Visual Impairments? (5x)

Answer 4

• Injury (especially those that result in Enucleation aka removal of the eye ball)
• Disease (such as glaucoma or diabetic retinopathy)
• Congenital Conditions (such as cerebral palsy)
• Infection
• Degeneration of the retina, optic nerve, or nerve pathways

Whatever the cause it is important to find out if the impairment is new and possibly the result of a current illness or if it is permanent and has been there a long time

Question 5

How to recognize visual impairments and accommodations you can offer

Answer 5

• depending on the degree of impairment you may or may not be able to tell. But often, especially if totally blind, it will be obvious
• an obvious sign is the use of a SERVICE DOG. DO NOT pet or disturb the dog while it is wearing it’s harness, that is the sign it is working. Ask permission to touch the dog but no not grab it’s collar, leash, harness, or patient’s arm without permission as that may place everyone in danger. transporting the dog will be dependent on your services protocols.
• if a service dog is not used, inquire with the patient if there are other tools used.
• always identify yourself on approaching the pt so they know you are there

Question 6

What are the 4 types of speech impairments?

Answer 6

LANGUAGE DISORDERS:
- This is the impaired ability to understand the spoken or written word.
- In children it can be caused by congenital learning disorders, cerebral palsy, or hearing impairments.
- In adults it can be caused by strokes, aneurysms, head injury, brain tumor, hearing loss, or emotional trauma.
- The loss of ability to communicate in speech or writing is known as Aphasia and can manifest itself as:
A) Sensory Aphasia: a person who can no longer understand the spoken word. (pts cannot understand you)
B) Motor Aphasia: Can no longer use symbols of speech (they can understand you but not articulate a response)
C) Global Aphasia: when a person has both sensory and motor aphasia

ARTICULATION DISORDERS:

• aka Dysarthria
• when sounds are produced or put together incorrectly in a way that makes it difficult to understand the spoken word
• Can occur in adults and children and arises when neural damage causes disturbances in the nerve pathways leading from the brain to the larynx, mouth, or lips
• pts will pronounce words weird or slur their speech

VOICE PRODUCTION DISORDERS:

• Quality of the persons voice is affected
• Can be caused by trauma, overuse of the vocal chords, infection, or vocal chord tumor
• May sound hoarse, use an inappropriate pitch, total voice loss, or abnormal nasal resonance.

FLUENCY DISORDERS:
- This is stuttering

Question 7

Accommodations for speech impairments

Answer 7

• do not rush the patient
• do not assume a lack of intelligence
• use questions that require short, direct answers
• let them write responses if needed
• do not fake understanding the pt when you don’t

Question 8

Obesity and related etiologies

Answer 8

Obesity is when a person is 20-30% heavier than is normal for a person of similar age, gender and height

The most often cause is a high caloric intake but also exercise and lifestyle play a part

Generic factors also play a role in predisposition towards obesity such as a low basal metabolic rate or hypothyroidism

Question 9

Accommodations for the obese

Answer 9

The obese patient may blame signs and symptoms of an untreated illness on their weight. For example a person may blame their dyspnea on being obese but you cannot accept that at face value, you must rule out all other causes.

You may have to adjust assessment techniques such as placing ECG monitors on the arms and legs for a better read or auscultate the lungs anteriorly on a pt who is too obese to lean forward.

You may require additional people or tools to move the pt, always ensure your own safety and that your equipment can handle the weight

Question 10

Paraplegic VS Quadriplegic

What are some things to keep in mind with a paralyzed person?

Answer 10

A Paraplegic is when the person is paralyzed from the waist down, a Quadriplegic is when the person is paralyzed in all 4 extremities

If you truck is equipped you should use your on board ventilator to save the battery power of the pts ventilator (this is when the pts diaphragm is paralyzed or partially paralyzed.

You may run into a colostomy bag that is used when the pts bowels are paralyzed or not functioning properly

Question 11

What are developmental disabilities and what can cause them?

Answer 11

It is when a person is impaired or insufficient development of the brain who are unable to learn at the usual rate.

This can be caused by genetic factors, down syndrome, or the product of brain injury caused by some hypoxic or traumatic event

(the book discusses down syndrome and fetal alcohol syndrome)

Question 12

Accommodations for developmental disabilities

Answer 12

may have to obtain info from others

pt may try to cover up events leading up to from fear of reprisal of doing something their caregivers deems “stupid”

may not trust you or have been taught to stay away from those who are going to “touch” them, so you may have to establish trust or have someone near whom the pt does trust

in severe cases, keep the primary care giver with you at all times, even in truck , and remember that they may not understand what is happening and be afraid

Question 13

Down Syndrome

Answer 13

It is caused by an extra chromosome often on number 21 or 22 (normal amount is 46 but they have 47)

Chances of this increase when the mother is above 40 or has chromosomal abnormalities herself

The typical features of someone with down syndrome include:

• eyes that slope at the outer corners
• folds of skin on either side of the nose that cover the inner corner of the eye
• small face and features
• large protruding tongue
• flattened back of the head
• short and broad hands

They will also often have other defects as well in the heart, lungs, or bowels. and are prone to cataracts, blindness, and Alzheimer’s at an early age

Question 14

Characteristics of Fetal Alcohol Syndrome (FAS)

Answer 14

• Small head with multiple facial abnormalities
• Small eyes with short slits
• Wide, flat nose bridge
• Lack of groove between the nose and lip
• Small jaw

They often exhibit delayed physical growth, mental disabilities, and hyperactivity

Question 15

What are the pathological challenges discussed in the chapter?

Answer 15

Arthritis
Cancer
Cerebral Palsy
Cystic Fibrosis
Multiple Sclerosis
Muscular Dystrophy
Poliomyelitis
Previous Head Injury
Spina Bifida
Myasthenia Gravis

Question 16

What are the 3 most common types of Arthritis?

Describe arthritis as a pathological challenge

Answer 16

• Juvenile Rheumatoid Arthritis (JRA): connective tissue disorder that strikes before age 16
• Rheumatoid Arthritis: autoimmune disorder
• Osteoarthritis: degenerative joint disease, the most common arthritis seen in the elderly

Arthritis causes painful joint swelling and irritation of the joints as well as joint stiffness and limited range of motion.

Treatment includes aspirin, NSAIDs, or corticosteroids. But be aware of the adverse effects of these drugs

NSAIDs can cause upset stomach and vomiting, with or without bloody emesis

Corticosteroids can cause hyperglycemia, bloody emesis, and decreased immunity

Question 17

Cancer as a pathological challenge

Answer 17

• Cancer is a blanket term for many different types of diseases but all have in common the abnormal growth of cells in normal tissues
• The primary origin of the cancer cells determines the type of cancer it is. (Ex. in epithelial tissue = carcinoma ; in connective tissue = sarcoma)
• Sign of a cancer patient mostly come from the side effects of treatments such as alopecia (loss of hair), anorexia (loss of apatite), tattoos left on skin for radiation positioning, or mastectomy (breast removal)
• ***Most cancer pts who undergo chemotherapy suffer secondary Neutropenia (low white blood cell count) b/c the neutrophils are destroyed in chemotherapy. This places them at very high risk of infection and can go septic very quickly. If they have had recent treatments you should assume they are neutropenic
• Pt veins may also be very scarred and stiff making difficult access. There are 2 common alternatives.
  1) Pts may have an implanted fusion port that goes into the subclavian artery. However you need special training to do this and protocols may say you cant. But if you do you must use a sterile technique and it must be ok with the pt. If you cannot use it but the pt does not want you to start a peripheral IV then you need to consider if the pt can wait till getting to the hospital for them to access it or if immediate IV access with save their life.
  2) There are also peripheral access devices such as a Groshong or Hickman catheter access ports that may be easy to use after a simple flush. But make sure the pt is ok with it.

Question 18

What is cerebral palsy as a pathological challenge and what are the 3 types?
What can cause it?

Answer 18

Cerebral palsy is a group of disorders caused by damage to the cerebrum in utero or by trauma during birth. If the mother had German Measles in the first trimester, any event that caused hypoxia, encephalitis, meningitis, or head injury can all cause cerebral palsy. It will result in difficulty controlling motor functions and spasticity of the muscles.

The 3 main types are:
- Spastic Paralysis: The most common form and involves the muscles being forced into a constant state of permanent stiffness and contracture. When affecting both legs the knees turn inward causing the key sign of a “scissor gate”

• Athetosis: involuntary writhing movement usually in the arms, hands, legs, or feet. It can also affect the face causing drooling or a grimaced look.
• Ataxic Cerebral Palsy: the rarest form that causes problems with coordination of gait and balance

These patients are still capable of high intelligence (i think steven hawking had this) and remember that they may depend on wheel chairs and may not sit comfortably on a stretcher, needing pillows for support

Question 19

What is Cystic Fibrosis as a pathological challenge?

Answer 19

Cystic Fibrosis is an inherited disorder that involves the exocrine glands, primarily in the lungs and digestive system. Thick mucus forms in the lungs, causing bronchial obstruction and atelectasis. Thick mucus also forms blockages in the small ducts of the pancreas, leading to decrease pancreatic enzymes needed for digestion, this causes malnutrition even for a pt with a healthy diet.

A way to determine if a pt has this is by a “sweat test” that tests their sweat for abnormally high levels of chloride in the sweat. They also may have frequent lung infections, clay-colored stool, or clubbed fingers/toes

Oxygen (often by cpap), suctioning, and antibiotics are often needed. They will usually have a regular dose of Atrovent or something to thin the secretions.

Question 20

What is Multiple Sclerosis? (Pathological disorder)

Answer 20

It is considered an autoimmune disorder but is ultimately another Pathological Challenge. It is when repetitive inflammation of the myelin sheath causes scar tissue that results in blocking nerve impulses.

The onset is slow and often starts with just a slight change in the strength of a muscle or numbness/tingling but by the end will cause many more problems that may ultimately lead to death.

It often strikes at the ages of 20-40 and women more than men

Question 21

What is Muscular Dystrophy? (Pathological disorder)

Answer 21

It is a hereditary/genetic disorder that leads to gradual degeneration of muscle fiber.

The most common form is Duchenne MD which typically affects boys at the ages of 3-6, starting off with muscle weakness in the legs and pelvis and moving to paralysis by the age of 12. Ultimately the disease will affect the respiratory muscles and heart causing an early death

Question 22

What is Poliomyelitis? (Pathological disorder)

Answer 22

It is a highly contagious disease that affects the gray matter of the brain and the spinal cord. The disease enters through the GI tract, then enters the blood stream and travels to the central nervous system and finally to the nerve cells.

Paralytic Polio causes asymmetrical muscle weakness that progresses to paralysis in the legs or lungs. This is why most polio pts who did not receive the vacc before it was invented in the 50s may be in a wheel chair or on a ventilator

There is also Post-Polio Syndrome in which as long as 30 years later pts will become progressively tired quicker and develop an intolerance for cold extremities.

Question 23

What is Spina Bifida? (Pathological disorder)

Answer 23

• It is considered an congenital abnormality affecting the neural tube. It is when there is a defect in the closure of the backbone and the spinal canal.
• There is Spina Bifida Occulta; in which the pt exhibits few outward signs of deformity
  or
  There is Spina Bifida Cystica; the failure of the closure allows the spinal cord and covering membranes to protrude from the back causing obvious deformity.
• Symptoms depend on which part of the spinal cord is protruding through the back
• A high percentage of pts have HYDROCEPHALUS which is excess fluid on the brain and require a shunt be placed to help drain off the fluid. I believe the shunt goes from head to abdomen somewhere
• Also a large percentage have a LATEX ALLERGY, so assume they have it

Question 24

What is Myasthenia Gravis? (Pathological disorder)

Answer 24

Myasthenia Gravis is when there is a problem with the neurotransmitters, causing a blockage of nerve signals to the muscles. This results in the characteristic chronic weakness of voluntary muscles and progressive fatigue.

It may also affect muscles in the face causing eyelid drooping, or difficulty chewing/swallowing as well as possible double vision. They will probably complain of complete lack of energy especially in the evening.

In extreme cases it can cause paralysis of the respiratory muscles.