Student-Elder Abuse-Clinical Dilemma PDF

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Elder Abuse/Vulnerable Adult Clinical Dilemma Activity

John Peterson, 82 years old

Primary Concept Interpersonal Violence Interrelated Concepts (In order of emphasis)     NCLEX Client Need Categories Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies  Reduction of Risk Potential  Physiological Adaptation

Stress Coping Anxiety Ethics Percentage of Items from Each Category/Subcategory

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

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6-12% 12-18% 9-15% 11-17%

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I. History of Present Problem: John Peterson is an 82-year old male who is brought to the emergency department (ED) by his son because of concerns of caregiver neglect. John lives in his apartment and requires help with ADLs during the day. When the son visited his dad, he found him soaked in urine, surrounded by spoiled food, with dried vomit on his clothing. The trash cans outside the home were overflowing, and inside, there was debris and old food left on the bedroom and kitchen floors. John is complaining of pain in his feet, which he attributes to his diabetes. The son reports that his current caregiver is a family friend who has a history of drug addiction and may have relapsed. The patient is alert and oriented and admits to feeling sickly. He does not remember when he last had a glass of water. There is a distinct smell of feces and urine. Upon closer assessment, there are dried feces in his perirectal area with a large red swollen scrotum and redness in his groin folds. There is also evidence of skin tears/bleeding on the left lateral thigh that appeared to be of a friction/shear type mechanism. Mr. Peterson states that he has not had a bath in three weeks. He also reports being unable to get up from the chair by his bed without assistance for the last three days because of increasing weakness and fatigue.

Personal/Social History: Mr. Peterson’s son, Frank, reports that the patient was relatively healthy and self-sufficient up until the age of about 77. His first wife, Frank’s mother, died 20 years ago. He remarried two years after his first wife died. Frank and his father’s second wife, Janet, did not get along well, which resulted in a more distant relationship between father and son. Frank lives about four hours away, is an only child, and visits 2-3 times a year. When Janet died a year ago, it first became apparent that John needed help with day to day functioning. John was resistive to leaving his home or having “strangers” come into his house but finally agreed to let a family friend help out. During a previous visit, Frank noticed that his father had a frailer appearance and was more forgetful. It has been about three months since his last visit. Frank reports that his father does not have many visitors or close friends that are still alive. What data from the histories is important & RELEVANT; therefore, it has clinical significance to the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: -

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Soaked in urine Spoiled food Dried vomit on his clothing Trash cans overflowing Old food left on bedroom and kitchen floors Pain in his feet Feels “sickly” Cannot recall last time he drank water Dried feces in perirectal area with large red swollen scrotum/redness in groin Skin tears/bleeding in L lateral thigh – friction/shear type mechanism Has not had a bath in 3 weeks Unable to ambulate from chair to bed because he has increased weakness and fatigue Distinct smell of feces and urine Hx of diabetes

RELEVANT Data from Social History: -

Lives alone Caregiver to help with ADLs Current caregiver is a family friend who has hx of drug addiction who may have

Clinical Significance: Patient is unable to perform his ADLs without assistance and the caregiver is neglecting the patient. His health is deteriorating and skin integrity has been compromised. He is at risk for infection. Patient is also showing signs of dehydration with weakness, fatigue, dried vomit on his clothing and patient is unable to recall the last time he had a glass of water. This is also significant because the patient has diabetes. He could become a risk for renal related issues.

Clinical Significance: Patient does not engage in social interactions and is distant from his son. He does not have a reliable social network who can help take care of him. His current caregiver is showing neglect based on the patient’s physical status. Patient is isolated and may not have a method to contact anyone for help.

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relapsed Was self sufficient until the age of 77 2nd wife of Patient did not get along well with son, Frank, so they became more distant – visits 2-3 times a year Son has noticed patient seems more frail and is more forgetful Does not have many visitors or close friends that are still living

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Resolving the Dilemma 1. Interpreting RELEVANT clinical data, what is the essence of this clinical dilemma and the current priority? (NCLEX: Management of Care)

The patient is showing significant signs of caregiver neglect. The patient was found soaked in his own urine, dried feces on his perirectal area, swollen, red scrotum and tears/bleeding on L thigh. He is also showing signs of weakness and fatigue and cannot recall the last time he had water. The patient is also diabetic, and given that he could possibly be dehydrated, this can increase the risk for renal dysfunction. 2. Identify the differences between patient abuse and neglect. What are the most common findings that are clinical RED FLAGS for the nurse?

Patient abuse is the act of purposely physically striking or assaulting a patient. It is also intentionally withholding necessary food, physical care and medical attention. Patient neglect is the failure to provide standards of care and is unintentional.

3. What is the nurse's role in reporting suspected abuse, neglect, or exploitation?

The nurse must report the abuse, neglect or exploitation to authorities as well as the nursing manager to appropriately handle responsibility.

4. What additional information is needed by the nurse to clarify the dilemma? (NCLEX: Management of Care)

In depth assessments including physical, emotional, social and psychological aspects. These assessments need to be extremely thorough and accurate. Getting assessments from family may also be helpful.

5. What additional members of the healthcare team can be used in this situation? Why? (Management of Care)

Psychologists, sociologists, dieticians, nutritionists, physical therapist, home health nurse. All of these people play a vital role in establishing in depth assessments and diagnosis. The home health nurse can determine if the patient’s home is safe and reliable for the patient to continue to live alone. Nutritionist and dieticians can help the patient with Meals on Wheels or additional programs for proper nutrition. Sociologists may be able to help the patient find social gatherings/ means of transportation to establish healthy relationships with new friends. Psychologist may be able to help and maintain a positive and more open relationship between son and father.

6. What does the nurse need to know to provide culturally competent care? (NCLEX: Management of Care)

The nurse needs to ask questions regarding religion, culture, favorite foods, hobbies and what they patient things health means. Must also establish the type of relationship there is between father and son and

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promote socially acceptable methods of health and wellness based on the patients values and likes. Reading body language is also important and understanding non-verbal cues.

7. What is the nursing PRIORITY? (NCLEX: Management of Care)

Impaired skin integrity r/t altered dermis/epidermis aeb patient being soaked in urine, having dried feces in perirectal area with a large red swollen scrotum and redness in his groin area, skin tears, bleeding on the left lateral thigh from friction/shearing. 8.

What are the PRIORITY nursing interventions? (NCLEX: Management of Care) PRIORITY Nursing Interventions: Rationale:

Inspect and monitor site of skin impairment every 6 hours for color changes, redness, swelling, warmth, pain, or other signs of infection.

Systemic inspection can identify impending problems

Implement a topical treatment and proper wound A treatment plan shows consistency in care and dressings that will promote healing on the site of documentation skin impairment until discharge as ordered by physician

Provide full bed bath using normal saline and skin barrier cream to clean impaired skin as ordered by the health care provider within 30 minutes.

Reduce the skin of additional skin breakdown and promote healing

Expected Outcome: Patient’s skin will show signs of healing and reduced redness

Topical treatments and wound dressings will protect the skin from infection and additional trauma. The use of normal saline as water to rinse will help keep skin clean. Barrier cream will protect the skin from additional shearing or friction.

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9. What principles of therapeutic communication can be utilized to develop trust and encourage dialogue between the nurse, patient, and/or family? (Management of Care) and (Psychosocial Integrity)

Using touch and sitting close to the patient will show you are listening and that you care. Looking the patient in the eyes will also show him that you are listening. Discussing the entire plan with the patient and the patient’s family and encouraging feedback are also examples to show a patient you are communicating effectively. 10. What is the expected response of the patient/family/caregiver (Management of Care)?

The expected response would be relief from the patient and family that they will get the best care possible. Everyone involved will be able to trust and communicate and work together as a team to develop and implement the best care plan. 11. What is the patient and/or family likely experiencing/feeling right now in this situation? (Psychosocial Integrity/Basic Care and Comfort)

The patient is probably depressed and feeling isolated. He probably thinks that nobody cares and he was left to suffer. The son is probably depressed and feeling regretful for not being there for his father. They are both probably extremely frustrated and angry about the care he was given/ lack of care.

12. What can I do to engage myself with this patient’s experience, and show that the individual matters to me as a person? (Psychosocial Integrity/Basic Care and Comfort)

Be positive, smile. Encourage the patient and the patients family to start fresh and make positive changes that everyone can agree on. Make sure they understand there is light at the end of the tunnel. Put on favorite music or tv shows. Have the patient assist in bathing, if possible. Ask stories about family and the past. Encourage open dialogue and advocate % for the patient and their family. They are in need.

Reflect on Your Thinking to Develop Clinical Judgment To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study?

What knowledge gaps did you identify?

I think one thing I did well was critically think. I read the Diabetes and fluid/electrolyte balance must be observed CBC and electrolyte labs should be requested to determine if study and determined that the patient’s hydration and there are additional problems such as insulin, infection and nutrition status were at risk. However, I took it a step further and remembered that the patient is also diabetic. electrolyte imbalances that we cannot see with the eye. So, as a nurse, I do have to ensure there is a fluid and nutrition balance, but I also have to monitor the patients diabetes (renal issues) due to imbalance. What did you learn? How will you apply learning caring for future patients? I learned that even if a patient needs help at home and are The patient and the family are most likely at a point of mistrust not getting proper care, they might not call for help or and anger. I will apply the use of therapeutic touch and take my © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

report it. I learned that a psychological assessment is probably another important tool is assessing a patient’s capability of being cared for either by taking care of themselves or asking for help.

time with this patient and the family. I will ensure that when the patient is discharged, they will get the proper home health care and that they are capable of living at home alone. This patients health could have deteriorated much quicker had the son not intervened when he did.

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Nursing Plan of Care (please refer to rubric when completing this form) Objective Cluster Data (for this problem) Pt had dried feces in perirectal area Large red swollen scrotum Skin tears and bleeding in L lateral thigh from friction/shearing

Redness in groin area

Patient Initials: Subjective Cluster Data (for this problem) Patient’s son found patient soaked in urine Patient states he has not had a bath in 3 weeks Patient states he is unable to ambulate from chair to his bed without assistance for 3 days because he feels weakness and fatigue. Patient’s son states current caregiver is a family friend who has a hx of drug addiction and may have relapsed

Nursing Problem (Diagnosis) #1: Impaired skin integrity r/t altered dermis/epidermis aeb patient being soaked in urine, having dried feces in perirectal area with a large red swollen scrotum and redness in his groin area, skin tears, bleeding on the left lateral thigh from friction/shearing. Goals (List one short term and one long term goal) STG: Patient will begin to regain integrity of the skin’s surface within 24 hours. STG Interventions (List 3, with rationales & citation) 1. Inspect and monitor site of skin impairment every 6 hours for color changes, redness, swelling, warmth, pain, or other signs of infection. Systemic inspection can identify impending problems (NPUAP/EPUAP, 2014) 2. Implement a topical treatment and proper wound dressings that will promote healing on the site of skin impairment until discharge as ordered by physician. A treatment plan shows consistency in care and documentation (Baronski & Ayello, 2016) 3. Provide bed bath using normal saline and skin barrier cream to clean impaired skin as ordered by the health care provider within 30 minutes. Reduce the skin of additional skin breakdown and promote healing (Scemons, 2013) LTG: Patient will demonstrate the understanding of plan to heal skin and prevent reinjury or complications before discharge. LTG Interventions (List 3, with rationales & citation) 1. Implement an incontinence management plan with patient and family. Urinary and fecal incontinence can cause skin breakdown (NPUAP/EAUAP, 2014). 2. Initiate a consultation with home health nursing to ensure patient receives proper at home care before discharge. A home visit by home health or wound care specialist can provide essential in-home education and client specific plans of care. (Vrtis, 2013) 3. Teach the client and family how to assess skin and wounds for signs and symptoms of infection Systemic inspection can identify impending problems (NPUAP/EAUAP, 2014). Evaluation: (State if goals were met/not met and why; If goal should continue/discontinue or be revised) STG: Patient’s goal was met within 20 hours. Patients skin began to show signs of healing after saline cleansing, the use of skin barrier cream and topical treatment. Skin tear began to also show signs of healing.

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LTG: Patient’s goal was met. Patient and family were able to verbalize the need for proper home-health care and patient seemed relieved to meet with home health care team to implement a new home plan.

Patient Initials: Objective Cluster Data (for this problem) Patient has hx of Diabetes Patient has dried vomit on his clothing

Subjective Cluster Data (for this problem) Patient states he cannot recall the last time he had a glass of water Patient states he is weak and fatigued Patient states he has been unable to ambulate from chair to bed for 3 days Patient’s son states he found his dad surrounded by spoiled food Patient states he has pain in both feet

Nursing Problem (Diagnosis) #2: Deficient fluid volume and nutritional intake r/t caregiver neglect aeb patient’s states that he cannot remember when he had a glass of water, dried vomit on his clothing and patient states he has been unable to ambulate from his chair for the last three days because he feels weak and fatigued. Goals (List one short term and one long term goal) STG: Patient will show a decrease in weakness and fatigue within 4 hours. STG Interventions (List 3, with rationales & citation) 1. Monitor for factors associated with hypovolemia such as vomiting, uncontrolled diabetes, dry tongue and oral mucosa. Identifying risk factors and intervening early can decrease the occurrence of severe complications from deficient fluid volume and acute kidney injury. (Ftouh & Lewington, 2014) 2. Monitor I/O every 4 hours. Fluid intake and output is an indicator of fluid imbalance. (Schrezenmeier et al, 2017) 3. Hydrate the client with isotonic IV solutions as prescribed or provide fresh water and oral fluids preferred by the client over 24 hours. Distributing intake over 24 hours and providing snacks with creatine and carnitine, and caffeine may improve muscular ability, endurance an...