Presentation on theme: "Assessing Patients for Signs of Elder Mistreatment"— Presentation transcript:
1 Assessing Patients for Signs of Elder Mistreatment Module 7Nursing Responses to Elder MistreatmentAn IAFN Education CourseThe course curriculum was developed by the International Association of Forensic Nurses (IAFN) under grant #2003-DD-BX-K006 from the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice.
2 Learning ObjectivesDiscuss steps of assessment for elder mistreatment (EM)Recognize signs in cases of neglect, physical abuse, emotional/psychological mistreatment, sexual abuse, abandonment, financial exploitation and violation of personal rights
3 Case Study: Mrs. AmosWhat are the signs of potential mistreatment in this case?What is the nurse’s role in this situation? What else does she need to do?
5 Identification through… Physical examinationDiscussions with patients, family members and caregiversReview of medical records
6 Evaluation Considerations Patient issues and circumstances that influence findingsImplausible explanations and inconsistencies regarding history of injury and illnessWhether nature of signs agree with what patient, family members and/or caregiver tell you
7 Documentation Thorough Accurate Objective In accordance with agency policy
8 General Assessment Approach AMA’s Diagnostic and Treatment Guidelines for Elder Abuse and Neglect (1992)SafetyAccess to PatientCognitive StatusEmotional StatusHealth and Functional StatusSocial and Financial ResourcesFrequency and SeverityAssessing for intent is not nurses’ duty.
9 Signs of Neglect Return to Case of Mrs. Amos: What are some of the signs of neglect you identified in this case?
10 Signs of Neglect Poor hygiene Malnutrition Dehydration Inadequate medical careAbsence of physical aidsOver/under medicationContracturesPressure ulcers, untreated or under-treatedAdapted from T. Fulmer, G. Paveza, I. Abraham & S. Fairchild, Elder neglect assessment in the emergency department, Journal of Emergency Nursing, 2000Source for Photo: The John A. Hartford Foundation Institute for Geriatric Nursing, New York University, College of Nursing. Photography by James Schuck.
11 Stage 1 Pressure UlcerIntact skin with non-blanchable redness of a localized area usually over a bony prominenceDarkly pigmented skin may not have visible blanching; its color may differ from the surrounding areaArea may be painful, firm, soft, warmer or cooler as compared to adjacent tissueStage I may be difficult to detect in individuals with dark skin tonesMay indicate "at risk" persons (a heralding sign of risk)Slide from National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System, 2007,in M. Baker, The Scope and Consequences of Elder Mistreatment: The Tip of the Iceberg (handouts from presentation),Northwest Geriatric Education Center Geriatric Health Promotion Series, University of Washington. Seattle, WA; March 2010
12 Stage 2 Pressure UlcerPartial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without sloughMay also present as an intact or open/ruptured serum-filled blisterPresents as a shiny or dry shallow ulcer without slough or bruising
13 Stage 3 Pressure UlcerFull thickness tissue lossSubcutaneous fat may be visible but bone, tendon or muscle are not exposedSlough may be present but does not obscure the depth of tissue lossMay include undermining and tunnelingDepth of a Stage III pressure ulcer varies by anatomical location
14 Stage 4 Pressure UlcerFull thickness tissue loss with exposed bone, tendon or muscleSlough or eschar may be present on some parts of the wound bedOften include undermining and tunnelingThe depth of a Stage IV pressure ulcer varies by anatomical locationStage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possibleExposed bone/tendon is visible or directly palpable
15 Unstageable Pressure Ulcers Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed
16 Signs of Neglect Emotional/psychological Withdrawal Depression AgitationInfantile behaviorAmbivalent feelings toward family members or caregivers
17 Signs of Physical Abuse Context and location of injuries criticalInjuries in various stages of healing may indicate abuseHidden injuries typical of abuseAbuse tends to be central, accidents distalCalifornia District Attorneys Association, CDAA elder physical and sexual abuse:The medical piece, part 1 & 2 (Learning point summaries template), 2003
18 BruisingA bruise, or contusion, occurs when blunt forces distort soft tissues to an extent sufficient to result in disruption and leakage of blood vesselsEscape of blood from blood vessels produces discolorationP. Besant-Matthews, Blunt and sharp injuries, in V. Lynch, Forensic nursing, 2006
19 Bruising in Geriatric Pop. 2009 study by A. Wigglesworth, R. Austin, M. Corona, D. Schneider, S. Liao, L. Gibbs, and L. Mosqueda, Bruising as a Marker of Physical Elder Abuse, Journal of the American Geriatric SocietyPhysically abused older adults had significantly larger bruises than those in comparison group who were not abused and more knew the cause of their bruisesPhysically abused older adults more likely to have bruises on face, lateral aspect of right arm and posterior torso than older adults from an earlier study who had not been abused
20 Bruising in Geriatric Pop. Earlier study-Nearly 90% of bruises on extremitiesNot a single accidental bruise observed was on neck, ears, genitalia, buttocks or soles of feetOf 20 large bruises in this study, only one was on trunkOlder adults are significantly more likely to know how the bruise happened if it is on the trunkL. Mosqueda, K. Burnight & S. Liao, Bruising in the geriatric population, 2006, as cited in Baker
21 Patterned InjuryAn injury that possesses features or configuration with objects or surfaces that produced itW. Smock, Forensic emergency medicine,in J. Olshaker, M. Jackson and W. Smock (Eds.), Forensic emergency medicine, 2001
22 Patterned Injury Grip marks around arms or neck Rope marks or welts on wrists or anklesImprints from belts, belt buckles, straps, cords, hangers, hairbrushes, combs, cigarettes and cigarette lightersHandprints, fingerprints, knuckle prints and footprintsMore on strangulation…More on burns…
23 FractureBroken bonesIncludes severing of the bone or compression of intact boneC. Bitondo Dyer, M. Connolly & P. McFeeley,The clinical and medical forensics of elder abuse and neglect,in R. Bonnie & R. Wallace, Elder mistreatment, abuse, neglect and exploitation in an aging America, 2003
24 AvulsionThe tearing away of a structure or part; often seen as a partial avulsion
25 AbrasionA wound in which the outermost layer of the skin is removed by a compressive or sliding forceBesant-Matthews
26 LacerationBlunt force injuries resulting from tearing, ripping, crushing, overstretching, pulling apart, bending and shearing soft tissue.Lacerations are usually found over a bony surface and are ragged or irregular in appearanceBesant-Matthews
27 IncisionIncision, known as a cut, is a wound made by a sharp instrument or object, such as a scalpel, knife, razor or paper coming against the skin with pressure to cause an injuryBesant-Matthews
28 Stab WoundResult whenever a sufficiently sharp and narrow object is forced upwardUnlike a cut, depth exceeds width in stab woundsBesant-Matthews
29 Mechanical Restraints Means of controlling behavior, especially in hospitals and nursing facilitiesOnly acceptable reason for temporarily restraining someone is to prevent significant harmB. Knight (Ed.), Simpson’s forensic medicine (11 ed.), 1997
30 Emotional/Psychological Abuse Feelings and behaviors associated with emotional/psychological abuse may not be obvious at time of assessment— have to ask questionsSame flags may also be reactions to other types of mistreatment
31 Sexual AbuseDuring assessment of a vulnerable older adult who has been sexually abused, what injuries, behaviors and evidence might the nurse describe?For nurse, what are some important things to consider, questions to ask and next steps to take when she suspects sexual abuse?
32 Signs of Sexual Abuse Examples of physical signs Bruising, inflammation, tenderness, abrasions or trauma around the breast or anogenital areaUnexplained venereal disease or genital infectionsUnexplained vaginal or anal bleedingTorn, stained or bloody underclothingMay/may not be obvious physical signs
33 Assessing Sexual Abuse Refer to sexual assault forensic examinersType of sexual victimization suspected will influence what is assessedAsk when last known sexual contact occurredCare of acute injuries and patient safety a priority over evidence collectionCooperation of the patient needed for examPreserve bodily evidence
34 Financial Exploitation, Abandonment, Violation of Personal Rights What are your experiences with vulnerable older adults who have been financially exploited? What are questions a nurse can ask to find out about possible financial exploitation?What are your experiences with vulnerable older adults who have been abandoned? What are questions a nurse can ask to find out about possible abandonment?What are your experiences with vulnerable older adults who have had their rights violated? What are questions a nurse can ask to find out about possible violation of personal rights?
35 AbandonmentIn addition to an actual complaint by older person of being deserted, signs of possible abandonment include:A vulnerable older adult with cognitive and physical impairments is left at a hospital emergency department without caregiver contact informationA vulnerable older adult with cognitive impairments is put on a bus with a one-way ticket to another town or stateA vulnerable older adult with cognitive impairments is left at a public buildingB. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A collaborative approach, 2007
36 Financial Exploitation Not always obvious—question for more infoExamples:Denying the vulnerable older adult a homeStealing a vulnerable older adult’s money or possessionsCoercing a vulnerable older adult into signing contracts or assigning power of attorneyPurchasing goods with a vulnerable older adult’s money for personal gainCoercing a vulnerable older adult into making changes in his/her willWhen a person entrusted to care for a vulnerable older adult fails to use available resources necessary to sustain/restore health and well-being of personBaker
37 Violation of Rights Not always obvious—question for more info Examples Denial of older adult’s right to privacyNot allowing older adult to make own decisions regarding health care or personal mattersRestricting interactions with othersForcible eviction and/or placement in a nursing homeElder abuse and neglect for EMS, EMSTopics.com, 2007