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Common Medical Issues For People Who are Homeless
Ellen M. Brown, RN, LCSW
DHHS Program Manager
Health Care for Homeless
Danielle Jacques, RN, MSN
Community Health Nurse II
Health Care for the Homeless
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IntroductionToday we’ll discuss
some common medical problems and the issues that arise in providing care to people who are homeless.
We will also review where to refer the homeless for primary medical care
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Why is this important? Studies show that 40% of
homeless suffer from one or more chronic health problems
Chronic diseases among the homeless are typically more severe than in people who are housed
The management of health problems is more difficult in the homeless.
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Homeless
Homelessness can be the cause of poor health
Poor health can lead to homelessness
Homelessness makes management of any health problem more
difficult
Health
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Objectives of this training: Be aware of the major health
problems encountered among people who are homeless
Gain knowledge into which clients should go immediately to the emergency room and which to refer for an appointment with primary care
Be knowledgeable of the primary care providers for homeless clients
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The Top Ten Medical Conditions
1. Upper respiratory infection 2. Skin problems
3. Dental problems 4. Hypertension
5. Diabetes 6. Asthma
7. Peripheral vascular disease 8. Allergies
9. Seizures 10. Joint Pain
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Upper Respiratory Infection
Prevention is important
Treatment is encourage fluids, take OTC meds, and rest
Need to make sure it’s not bronchitis, pneumonia, or allergies
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Common Cold vs. Serious Respiratory Infection
Routine visit Send to clinic ASAPend
Send to ER
Runny nose,Dry cough or small amt sputumGradual onset
Coughing up sputumNormal breathingCoughing up
Breathing rapidlyHas high feverSudden onsetSkin color not normal
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Skin Problems Many kinds of skin
problems; most are not contagious
Treat with creams or occasionally need oral meds
Watch out for lice or scabies
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Scabies Caused by a mite,
Sarcoptes scabei burrowing under the skin
Causes severe itching, especially at night
Transmitted by skin to skin contact, very contagious
Treatment: prescription cream wash clothes in hot water
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Frostbite
Caused when tissues freeze and ice crystals form and rupture causing tissue death
3 stages 1st redness and pain 2nd blistering 3rd deep red/purple, hard
Treatment is re-warming tissues and preventing infection
DO NOT Burn the skin by trying to reheat over an open fire
DO NOT rub skin, this causes further breakdown of tissues
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Fungal Infections
Can affect any part of the body
Can be contagious Often treated with
creams or other “topical” medications
Can take a long time to resolve
Can be recurrent
Athlete's foot
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Bacterial infections
Pus-filled blisters (“pustules”) or open wound draining purulent drainage
May have swelling, redness, warmth
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Is it MRSA? Methicillin Resistant Staphylococcus Aureus
Skin Infections Transmitted by skin
to skin contact Characterized by a
reddish rash with a boil
Requires aggressive antibiotic therapy
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Practice ‘Universal’ Precautions Wash your hands often, carry disposable
hand wipes Protect you hands from cracking Wear gloves when handing
contaminated items Cover open wounds and change
dressings when they are wet Properly discard all contaminated
materials by double bagging Clean soiled surfaces with a 1:10 bleach
solution
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Skin ProblemsRoutine visit Send to clinic
ASAPSend to ER
Bleeding stopped with pressure
Itchy lesions that don’t disturb sleep
Cut or sore: red puffyHuman bite that breaks skinSmall burn on top layer of skinItchy lesion, wet with blisters, trouble sleepingOpen wound that is draining
Deep cut and bleeding not stopped with pressureBurn over large areaItchy lesion with swelling, can’t breath
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Dental Problems Refer to primary
care for infections then dental clinic
May need antibiotics
May need pain meds
Need immediate care if extra-oral swelling occurs
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Teeth/Mouth ProblemsRoutine visit Send to Clinic
ASAPSend to ER
ToothacheNeeds dental cleaning
Bleeding gumsTooth knocked out and doesn’t have itToothache with swelling, bleeding,fever
Bleeding gums and takes blood thinnerTooth knocked out and has toothMouth sores-can’t eat or drinkSwollen face, can’t talk or can’t swallow
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Hypertension (HTN) HTN is elevated blood pressure More common in the homeless
population than in the general population
HTN is twice as prevalent in alcoholics than in non-alcoholics
HTN may have no symptoms Found on routine examination
HTN can be an emergency
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Hypertension: The keys to treatment
Try to avoid salt Avoid alcohol and drugs Take prescribed Medications Monitor BP
HCTZ Verapamil
Lisinopril Atenolol
Clonidine
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Heart and Circulation Problems
Routine Visit Send to Clinic ASAP
Send to ER
Running out of blood pressure pills in a few daysRunning out of blood thinner pills in a few days
Shortness of breath with movement or liftingIs out of meds
Chest pain & weakness, numbnessShortness of breathPale skinSweating
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Diabetes Symptoms may include excessive
urination, excessive thirst, fatigue
It is diagnosed through blood tests
Complications can include peripheral neuropathy (loss of feeling in extremities), kidney problems, eye problems
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Management of Diabetes
Clients need to monitor blood glucose with a glucometer, primary medical provides them
May be controlled with diet (avoid sugar) May need oral medication or insulin injections Clients need to have regular, balanced
meals. Timing is important. Dental and foot care is important
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Diabetes Routine visit Send to Clinic
ASAPSend to ER
Blood sugar less than 120 and feels well. Is taking meds regularly.
Running out of meds.
Blood sugar is getting higher.
Increased urination.
Out of meds.
Change in mental status, with either high or low sugar
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Asthma
A chronic inflammatory disease of the airways
Prevalent in people experiencing homelessness
Symptoms may include wheezing, dry cough at night, tightness in chest, especially when exercising
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Management of Asthma Inhalers
Oral meds
Control environment as possible
Flu vaccine, pneumonia vaccine
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Asthma Triggers Tobacco
Cold air
Perfume, paint, cleaning fluids
Allergens such as mites, pollen, cockroaches
Common cold, flu, other respiratory illness
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Asthma
Routine visit Send to Clinic ASAP
Send to ER
Can breath OK if uses inhalerHas enough meds/inhaler and is taking them
Trouble breathingIncreased use of “rescue” inhalerMore frequent coughing
Trouble breathing and unable to converseChange in skin color
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Peripheral Vascular Disease (PVD)
Includes a broad group of problems: chronic edema, cellulitis of the legs, phlebitis (blood clots)
Prevalence is 10-15 times greater than in general population
High rates are related to lifestyle: constant walking, inability to elevate feet during sleep
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Cellulitis as a result of PVD
Contributing factors: Malnutrition Lack of adequate rest Exposure to the
elements Limited access to
showers/hygiene Psych issues/substance
abuse
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Treatment of Peripheral Vascular Disease
Elevate feet as much as possible May use compression stockings or ace
bandages Proper footwear Patients with ulcers may need dressing changes Infected wounds may need antibiotics
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Peripheral Vascular Disease
Routine visit Send to Clinic ASAP
Send to ER
Swelling in feet or ankles by the end of the day, goes down in the AM
Persistent swelling of feet, ankles, legs
Swelling of feet, ankles, legs with shortness of breath or other symptoms
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Allergies There are many
types of allergies Possible symptoms
include sneezing, watery eyes, itching, skin rash or hives, wheezing, coughing, vomiting, diarrhea, swelling around the mouth…
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Allergies
Rarely, an allergic reaction can become life-threatening.
“Anaphylaxis” may begin with severe itching of the eyes, and rapidly progress to difficulty in breathing and swallowing, cramps, and shock.
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Management of Allergies
Oral antihistamine medications (Benadryl, Loratadine)
Skin creams
Nasal sprays
Control of environment
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Allergies
Routine visit Send to Clinic ASAP
Send to ER
Sneezing.
Rash but skin unbroken.
Swelling of an arm or leg
Skin rash with excoriation.
Sneezing, coughing
Swelling of the face or throat
Difficulty breathing or swallowing
Weakness
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Seizures This is most common neurological
illness in the homeless population.
The most common cause is alcohol abuse, followed by head trauma.
There are many other causes.
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What does a seizure look like?
Any of these: Sudden falling Passing out Drooling, frothing at mouth Grunting, snorting Breathing stops temporarily Uncontrollable muscle
spasms Teeth clenching Eye movements Unusual behavior Staring
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Management of Seizures
Requires good relationship with a primary medical care provider
Compliance with Medications
Controlling environmental factors
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What to do if someone has a seizure
Don’t panic Keep him from hurting himself by easing
to the ground or positioning him safely If possible, try to gently turn him on his
side Tell someone to call 911 Note how long the seizure lasts Don’t try to put anything in his mouth When it’s over, have him rest
comfortably. Don’t try to move him right away.
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Seizures
Routine visit Send to Clinic ASAP
Send to ER
Takes seizure meds but has had no seizures.
Is out of meds.
Reports having seizure
Witnessed seizure, esp. if for first time.
Prolonged seizure.
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Joint Pain
Back pain, hip pain, leg pain very common
Made worse by walking, sleeping on an uncomfortable bed
May be a sign of more serious disease
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Joint PainRoutine visit Send to Clinic
ASAPSend to ER
Past injury causing discomfort; still has feeling, joint can be used
New injury that is bruised, swollen, and painful; still has feeling, joint can be used
New injury. Bone is sticking outNo feelingCan’t move part of bodyChange in skin color
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Flu!
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Flu Symptoms Sudden onset of illness Fever higher than 100.4 Chills Cough Headache Sore throat Stuffy nose Muscle aches Feeling of weakness and fatigue Diarrhea, vomiting, stomach pain, esp in
children
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“High Risk” Medical Conditions Susceptible to
Flu Pregnancy Diabetes Heart problems Kidney Disease Immunosuppression Age over 65 Chronic lung disease
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Is it flu or a common cold?
Influenza Sudden fever, lasts 3-4
days Headache is common,
can be severe Aches and pains are
common and can be severe
Fatigue is common and can be severe
Common cold Fever is rare
Headache is rare
Aches and pains are rare
Sometimes mild fatigue
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Is it flu or a common cold?
Influenza Nausea, vomiting,
diarrhea in children, esp < 5 years old
Watery eyes rare Sneezing rare in early
stage Stuffy nose rare Chest discomfort
common and can be severe
Common cold Nausea,vomiting,
diarrhea are rare
Watery eyes is common Sneezing is common
Stuffy nose is common Chest discomfort rare
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Is it flu or a common cold?
Influenza Complications:
respiratory failure, worsening of chronic conditions
Can be fatal
Common Cold Complications: Earache,
congestion
Not fatal
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What to do for flu
Prevent spread of flu to others: Wash hands Dispose of tissues properly Clean counters/surfaces with usual
products Get a Flu Shot If you get sick, rest, drink fluids,
and treat symptoms
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Influenza
Routine visit Send to Clinic ASAP
Send to ER
Needs vaccine Underlying medical condition
Has had symptoms for 5 days and no better
Shortness of breath
Poor color
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Primary Medical Providers for Homeless
Community Clinic Inc. Serves uninsured men, women and children Contracted with HHS for uninsured homeless adults Participates with MA, PAC and Medicare 3 locations:
Gaithersburg Clinic 200 Girard St. Gaithersburg 301-216-0880 /Ride On #61 Silver Spring (Progress Place)
8210 Dixon St. Silver Spring 301-585-1250 / one block from SS Metro Takoma Park
7676 New Hampshire Ave. 301-431-2972 / Ride On # 15, 16, 17, 18
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Primary Medical Providers for Homeless
Kaseman Clinic Inc. Serves uninsured men and women Contracted with HHS for uninsured homeless
women Does not participate with any insurance Kaseman Clinic
8 West Middle Lane, Rockville, MD
301-917-6800 /Ride On # 46
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When you need help… Call DHHS Health Care for the Homeless
Danielle Jacques, RN, MSN240-777-3104 office240-277-1003 cell
Ellen M. Brown, RN, LCSW-C240-777-3963 office240-380-7717 cell
The National Health Care for the Homeless Council website: www.nhchc.org