Curriculum Update : Culturally Diverse Patients Geriatric Population Medications for Home Use

1. Curriculum Update:Culturally Diverse PatientsGeriatric PopulationMedications for Home Use Condell Medical Center EMS System March 2006 Site Code #10-7200-E-1206 Revised by Sharon Hopkins, RN, BSN EMS Educator

2. Objectives Upon successful completion of this module, the EMS provider should be able to: • understand the sensitivity required when caring for a culturally diverse patient population. • discuss the unique assessment and care necessary for the geriatric population • discuss common medications taken by the population and potential impacts with clinical presentations

3. Culturally Diverse Patients • Differences of any kind: race, class, religion, gender, sexual preference, personal habitat, physical ability • Good healthcare depends on sensitivity toward these differences • Every patient is unique • Westernized medicine is not accepted by all

4. Culturally Diverse Patients • Key points • Individual is the “foreground”, culture is the “background” • All people share common problems/situations • Not all people identify with their ethnic cultural background • Every patient needs to be treated equally • Do not force someone to have an intervention that is against their personal beliefs

5. Culturally Diverse Patients • Patients have the right to self-determination • If the patient is of legal age (18 or older, not emancipated), the patient has the right to refuse any care or treatment offered • Document what has been refused and why • The patient, or person authorized to consent, must sign for themselves • spouses, grandparents, older siblings, police officers cannot sign a refusal • if telephone permission is taken, witness by 2 persons, and EMS signs and adds the name of the person supplying permission

6. Culturally Diverse Patients • Respect the integrity of cultural beliefs • Patients may not share your explanation of causes of ill health and not accept conventional treatments • Recognize your personal cultural assumptions, prejudices and belief systems. • Avoid letting your prejudices interfere with patient care

7. Culturally Diverse Patients • Language barriers • your assessment and accuracy of interpretation will be hindered when a language barrier is present • if an interpreter is used, document their name and relationship • in some cultures, use of children is insulting to adults and seen as too much responsibility placed on the child • language lines are available - know your own department’s resources

8. Culturally Diverse Patients • Locale of practice • get to know the predominate cultures of your area • the more you understand the culture, the more effective a practitioner you can be • know resources available in your community

9. Culturally Diverse Patients And Body Language • Very important especially when a language barrier exists • Usually at a subconscious level • Components of body language • eye contact • facial expressions • proximity • posture • gestures

10. Body Language - Eye Contact • Can play a key role in establishing rapport • Failure to make eye contact can be a sign of dishonesty • Making eye contact can be a sign of disrespect in some cultures (Chinese) • Asians may be reluctant to make eye contact with a figure of authority

11. Body Language - Facial Expressions • One of the most obvious forms of body language • Can convey mood, attitude, understanding, confusion, other emotions • Smiles are usually universally understood • Smiling and winking can have different connotations

12. Smiling and Winking • Japanese - may smile when confused or angry • Others Asians - smile in friendly greeting • Latin Americans - winking is romantic, sexual • Nigerians - parents wink at children to have them leave the room • Chinese - winking is rude • Hong Kong - blinking is sign of disrespect and boredom • Filipinos - point to objects with eyes, not fingers • Venezuelans - finger pointing is impolite

13. Body Language - Proximity • Acceptability varies widely culture to culture • In the United States, twice the arm length is a comfortable social distance - 4-12 feet • Personal space is 1.5 - 4 feet • Different messages are interpreted when standing above, at, or below eye level • above eye level shows authority, can be intimidating • at eye level indicates equality • below eye level shows willingness to let patient have some control over the situation

14. Body Language - Posture • Range of attitudes conveyed from interest, respect, subordination, disrespect • Argentina - standing hands on hips suggests anger or a challenge • Taiwan - good posture extremely important • Some cultures impolite to show the bottom of the shoe because it is dirty; will not sit with a foot resting on opposite knee

15. Body Language - Gestures • Can replace or accompany verbal communication • Japan - rude to pass an item with one hand • Middle & Far Eastern cultures - left hand considered unclean - rude to pass items with left hand • In Europe, waving goodbye is raising the hand palm facing out, wiggling fingers back and forth • In Nigeria, this is an insult if the hand is too close to another’s face

16. Gestures • In Bulgaria & Greece, head nodding means no • In the USA, beckoning with 1 finger means “come here”. In some cultures it is insulting or obscene. • Indonesia - pointing is done with a thumb • Middle East - pointing with 1 finger is impolite • “OK” sign • obscene in Germany and Bulgaria • in Japan means zero or worthless

17. Cultural Diversity - Physical Contact • Eastern Europeans are comfortable with touching • Asians prefer less physical contact • Chinese are uncomfortable with physical contact but will use a handshake for greeting • Latin Americans show affection easily and handshakes are strong & warm • Egypt - tend to be touch oriented

18. Cultural Diversity - Gestures • Middle East - left hand reserved for hygiene. Don’t shake hands left-handed or accept a gift with left hand • Native Americans - offensive to step on a foot - apologize immediately

19. Culturally Diverse Patients - African Americans • Handshaking is appropriate • Eye contact is appropriate • Culture vocally expressive • Close friends tend to be viewed as “family” • Tends to be matriarchal society • Skeptical of westernized medicine

20. Culturally Diverse Patients - Arab Americans • Prefer handshaking • Direct eye contact acceptable • Verbally expressive • Family shares in decision making process • Folk remedies are common • soup, prayer • Fond of westernized medicine

21. Culturally Diverse Patients - Chinese Americans • Direct eye contact and speaking out may be viewed as being disrespectful • Nodding is a sign of respect and not understanding • Oldest males in the group make decisions • Folk remedies are common • May interact with westernized medicine

22. Culturally Diverse Patients - Mexican Americans • Handshaking is appropriate • May avoid eye contact out of respect • Tends to not complain of pain • Silence is maintained out of respect or due to not understanding • Males usually head of the household • Folk remedies are common

23. Culturally Diverse Patients - Financially Challenged • May refuse health care due to its costs • We need to be an advocate for these people and make sure they are offered initial medical screening • Know your community and county resources to offer to this group of people • As a reminder, use your own resources wisely

24. Culturally Diverse Patients - Financially Challenged • Signs of impairment • homelessness • chronic illness with frequent hospitalizations • poor personal hygiene • self-employment

25. Resources for Referral • PADS - public access to provide shelter • provide meals and shelter October 1 - April 30 • open 7 pm - 7 am • goals - • connect person with resources to be able to leave the street • commit to own effort for health and recovery • to gain personal and economic self-sufficiency with safe, affordable permanent housing • HealthReach Clinic - medical screening • 847-360-8800 (Waukegan)

26. Resources for Referral • Catholic Charities • to help families & individuals overcome tragedy, poverty, other life challenges • Lake County • adult agency 847-377-4504 • juvenile agency 847-377-7800 • Salvation Army 847-336-1800 • Connection Crisis & Referral Hotline 847-689-1080 • Department Chaplain • Hospital Social Worker

27. Culturally Diverse Patients • During Assessment and Management • Recognize need for assistive devices • Respect the patient’s beliefs • Ask permission to initiate procedures • Obtain interpreter if unable to communicate because of language barrier • Allow ample time and area of privacy • Notify receiving hospital of special needs

28. Groups By Region • Asian • Afghanistan, Armenia, Azerbaijan, Bahrain, Bangladesh, Bhutan, Brunei, Burma, Cambodia, China, Georgia, Hong Kong, India, Indonesia, Iran, Iraq, Israel, Japan, Jordan, Kazaksta, North Korea, South Korea, Kuwait, Kyrgyzstan, Laos, Lebanon, Malaysia, Maldives, Mongolia, Myanmar, Nepal, Oman, Pakistan, Phillipines, Qatar, Russia, Saudi Arabia, Singapore, Sri Lanka, Syria, Taiwan, Tajkistan, Thailand, Turkey, Turkmenistan, United Arab Eminates, Uzbekistan, Vietnam, Yemen

29. Groups By Region • Far East - the “orient” - East Asia and Southeast Asia • Brunei, Cambodia, People’s Republic of China, Republic of China, East Timor, Hong Kong, Indonesia, Japan, Korea Laos, Macau, Malaysia, Myanman, Phillipines, Thailand Vietnam • Asian American - • term used to describe East Asian peoples; older term was “oriental” • term refers to person of that ethnic decent born in or immigrated to the United States

30. Groups By Region • Eastern European • Albania, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Lataiva, Lithuania, Macedonia, Moldova, Poland, Romanis, Russia, Serbia & Montenegro, Slovakia, Slovenia, Ukraine

31. Groups By Region • Middle East - South & Central Asia, Southwest Asia, & Egypt • Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kurdistan Region, Kuwait, Lebanon, Oman, Palestinian Territories, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, Yemen • Native American • a person having origin in any of the original peoples of North American and who maintain cultural identity through tribal affiliation or community recognition

32. Groups By Region • Many groups overlap regions • Older population usually refer to themselves by their ethnic region (ie: Chinese, Mexican) • Younger population usually refer to themselves by racial terms (ie: Asian, Latino) • Cannot always judge the ethnicity based on appearances - ask the patient if you need clarification

33. Geriatrics

34. Challenges in the Geriatric Population • Fear of losing autonomy/independence • mobility - walking and by car • want to continue to live on own • Patient fears financial burden of hospitalization • Patient is embarrassed by burden they become to family and friends • Multiple disease processes affecting health • Difficulty in communicating pain and fears

35. Challenges in Dealing With the Geriatric Population • Patient fatigues easily • Many layers of clothing hamper detailed examination • Need for modesty and privacy • May minimize their symptoms • fear that they may be hospitalized, illness will cost money they don’t have, illness may cause nursing home or alternate living arrangements with lose of independence

36. Challenges in theGeriatric Population • Often suffer from concurrent illnesses • Chronic problems make assessment of acute problems difficult • Aging affects response to illness/injury • Social/emotional factors have great impact on health • Depression & isolation - highest suicide rates in people over 65

37. Sensory Related Changes • Vision • cataracts cause blurring of vision; unable to distinguish between blue & purple • if cataracts opaque (cloudy), may not see pupillary response with a penlight • be in front of person & make touch contact with the patient before beginning to speak • Hearing • decreased hearing • diminished sense of balance • speak slowly and distinctly; check for hearing aids; write notes if necessary

38. Taste & smell • altered (decreased sensitivity) • creates decreased appetite which causes poor nutritional condition • Touch • neuropathies cause decrease sensitivity to tactile senses • increased risk of injury without patient’s awareness (ie:burns from heating pads; sores on feet becoming infected) • Pain • lowered sensitivity - smaller amounts of pain medication are necessary

39. Communicating with the Geriatric Population • Make eye contact before speaking • Always identify yourself • Position yourself at the patient’s eye level • Locate hearing aid, eyeglasses, dentures • Turn on lights, turn off TV to minimize distractions • Use surname (Mr., Mrs., Ms.) until permission given to address patient otherwise • Be patient and gentle - give time for the patient to respond to your questions

40. Evaluating the Environment • Condition, cleanliness & safety of housing arrangement • Nutritional status & evidence of food quality & quantity in the home • Personal hygiene & evidence of ability to maintain self independently • Multiple prescription bottles with multiple prescribers noted • drugs may be negatively interacting if the patient has not informed all physicians of all medications they are taking

41. Obtaining A History in the Geriatric Population • Resources for medical information • “Vial of life” - form of vital medical & personal information placed in a container that is kept in refrigerator • red heart-shaped magnet placed on outside of refrigerator • medic alert tags • custom engraved bracelet or necklace with important information on medical conditions, drug & food allergies, prescribed medications, emergency contacts

42. Physiological Changes Affecting Mobility • Diminished vision • Loss of exercise tolerance • Diminished breathing capacity - become short of breath quicker and lose energy to complete tasks • Slowed psychomotor skills - losing independence • Decreased reflex time to prevent falls - more prone to injury

43. Mobility in Geriatrics • Bone loss affects mobility • Osteopenia - less than the normal amount of bone • Osteoporosis - bone mass so reduced that the skeleton loses its integrity and becomes unable to perform it’s supportive function • Loss of bone strength and size • Loss of flexibility • Vulnerable areas in women • spine, wrist, hip, collarbone, upper arm, leg, pelvis • Treatment - meds, weight bearing exercises like walking and lifting weights

44. Cardiovascular Changes in Geriatrics • Left ventricle thickens and enlarges (hypertrophy) decreasing compliance • Decreased responsiveness to catecholamine stimulation • Diminished ability to raise the heart rate in response to stress • Decreased function of SA & AV nodal cells increasing risk of dysrhythmias • Cardiac output decreased by 30%

45. Arteries become increasingly rigid • Increased blood pressure to pump through rigid blood vessels • Reduced blood flow to all organs • Decreased peripheral resistance • Widened pulse pressure - increasing systolic blood pressure • Heart muscle stiffens • Postural hypotension - vessels less reflexive and blood pressure drops when patient stands up too fast • Atherosclerosis - progressive, degenerative disease of medium and large sized arteries

46. Cardiovascular Disease • Risk factors for developing cardiovascular disease • Previous MI • Angina • Diabetes • Hypertension • High cholesterol level • Smoking • Sedentary lifestyle

47. Geriatrics and Acute Myocardial Infarctions • Elderly do not present with typical signs or symptoms of acute myocardial infarctions • Silent MI’s are marked by atypical complaints such as fatigue, nausea, abdominal pain and breathlessness • High index of suspicion for MI with unusual or absent warning signs/symptoms • Mortality doubles after age 70

48. Heart Failure • A clinical syndrome where the heart’s mechanical performance (pumping) is compromised and cardiac output cannot meet the body’s needs • Caused by: ischemia, valvular disease, dysrhythmias, hyperthryoidism, anemia, cardiomyopathy • In elderly, large incidence of non-cardiac causes • Generally divided into right and left heart failure • Ventricular output insufficient to meet the metabolic demands of the body

49. Heart Failure • Left ventricular failure • left ventricle fails as a forward pump • back pressure of blood in the pulmonary system leads to pulmonary edema • Right ventricular failure • right ventricle fails as a forward pump • back pressure of blood into the systemic venous circulation leads to venous congestion • Congestive heart failure • reduced stroke volume causes an overload of fluid in body tissues

50. Signs and Symptoms of Heart Failure • Dyspnea • Fatigue • Orthopnea - often sleeping on extra pillows to be more upright • Dry, hacking cough progressing to frothy sputum • Dependent edema due to right heart failure (check most dependent part of body depending on mobility - feet or sacral area) • Nocturia - urinating at nighttime • Anorexia, ascites (fluid in abdomen)