Assessing Patients for Signs of Elder Mistreatment

1
Assessing Patients for Signs of Elder
Mistreatment

• Module 7
• Nursing Responses to Elder Mistreatment
• An IAFN Education Course

2
Learning Objectives

• Discuss 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. Amos

• What are the signs of potential mistreatment in
  this case?
• What is the nurses role in this situation? What
  else does she need to do?

4
Assessment Steps

• Identify
• Evaluate
• Document

5
Identification through

• Physical examination
• Discussions with patients, family members and
  caregivers
• Review of medical records

6
Evaluation Considerations

• Patient issues and circumstances that influence
  findings
• Implausible explanations and inconsistencies
  regarding history of injury and illness
• Whether 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

• AMAs Diagnostic and Treatment Guidelines for
  Elder Abuse and Neglect (1992)
• Safety
• Access to Patient
• Cognitive Status
• Emotional Status
• Health and Functional Status
• Social and Financial Resources
• Frequency and Severity
• Assessing 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 care
• Absence of physical aids
• Over/under medication
• Contractures
• Pressure ulcers, untreated or under-treated
• Adapted from T. Fulmer, G. Paveza, I. Abraham
  S. Fairchild, Elder neglect assessment in the
  emergency department, Journal of Emergency
  Nursing, 2000

Source 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 Ulcer

• Intact skin with non-blanchable redness of a
  localized area usually over a bony prominence
• Darkly pigmented skin may not have visible
  blanching its color may differ from the
  surrounding area
• Area may be painful, firm, soft, warmer or cooler
  as compared to adjacent tissue
• Stage I may be difficult to detect in
  individuals with dark skin tones
• May indicate "at risk" persons (a heralding sign
  of risk)

Slide 11-15 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 Ulcer

• Partial thickness loss of dermis presenting as a
  shallow open ulcer with a red or pink wound bed,
  without slough
• May also present as an intact or open/ruptured
  serum-filled blister
• Presents as a shiny or dry shallow ulcer without
  slough or bruising

13
Stage 3 Pressure Ulcer

• Full thickness tissue loss
• Subcutaneous fat may be visible but bone, tendon
  or muscle are not exposed
• Slough may be present but does not obscure the
  depth of tissue loss
• May include undermining and tunneling
• Depth of a Stage III pressure ulcer varies by
  anatomical location

14
Stage 4 Pressure Ulcer

• Full thickness tissue loss with exposed bone,
  tendon or muscle
• Slough or eschar may be present on some parts of
  the wound bed
• Often include undermining and tunneling
• The depth of a Stage IV pressure ulcer varies by
  anatomical location
• Stage IV ulcers can extend into muscle and/or
  supporting structures (e.g., fascia, tendon or
  joint capsule) making osteomyelitis possible
• Exposed 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
• Agitation
• Infantile behavior
• Ambivalent feelings toward family members or
  caregivers

17
Signs of Physical Abuse

• Context and location of injuries critical
• Injuries in various stages of healing may
  indicate abuse
• Hidden injuries typical of abuse
• Abuse tends to be central, accidents distal
• California District Attorneys Association, CDAA
  elder physical and sexual abuse
• The medical piece, part 1 2 (Learning point
  summaries template), 2003

18
Bruising

• A bruise, or contusion, occurs when blunt forces
  distort soft tissues to an extent sufficient to
  result in disruption and leakage of blood vessels
• Escape of blood from blood vessels produces
  discoloration
• P. 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 Society
• Physically abused older adults had significantly
  larger bruises than those in comparison group who
  were not abused and more knew the cause of their
  bruises
• Physically 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 extremities
• Not a single accidental bruise observed was on
  neck, ears, genitalia, buttocks or soles of feet
• Of 20 large bruises in this study, only one was
  on trunk
• Older adults are significantly more likely to
  know how the bruise happened if it is on the
  trunk
• L. Mosqueda, K. Burnight S. Liao, Bruising in
  the geriatric population, 2006, as cited in Baker

21
Patterned Injury

• An injury that possesses features or
  configuration with objects or surfaces that
  produced it
• W. 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 ankles
• Imprints from belts, belt buckles, straps, cords,
  hangers, hairbrushes, combs, cigarettes and
  cigarette lighters
• Handprints, fingerprints, knuckle prints and
  footprints
• More on strangulation
• More on burns

23
Fracture

• Broken bones
• Includes severing of the bone or compression of
  intact bone
• C. 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
Avulsion

• The tearing away of a structure or part often
  seen as a partial avulsion

25
Abrasion

• A wound in which the outermost layer of the skin
  is removed by a compressive or sliding force
• Besant-Matthews

26
Laceration

• Blunt 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 appearance
• Besant-Matthews

27
Incision

• Incision, 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 injury
• Besant-Matthews

28
Stab Wound

• Result whenever a sufficiently sharp and narrow
  object is forced upward
• Unlike a cut, depth exceeds width in stab wounds
• Besant-Matthews

29
Mechanical Restraints

• Means of controlling behavior, especially in
  hospitals and nursing facilities
• Only acceptable reason for temporarily
  restraining someone is to prevent significant
  harm
• B. Knight (Ed.), Simpsons forensic medicine (11
  ed.), 1997

30
Emotional/Psychological Abuse

• Feelings and behaviors associated with
  emotional/psychological abuse may not be obvious
  at time of assessmenthave to ask questions
• Same flags may also be reactions to other types
  of mistreatment

31
Sexual Abuse

• During 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 area
• Unexplained venereal disease or genital
  infections
• Unexplained vaginal or anal bleeding
• Torn, stained or bloody underclothing
• May/may not be obvious physical signs

33
Assessing Sexual Abuse

• Refer to sexual assault forensic examiners
• Type of sexual victimization suspected will
  influence what is assessed
• Ask when last known sexual contact occurred
• Care of acute injuries and patient safety a
  priority over evidence collection
• Cooperation of the patient needed for exam
• Preserve 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
Abandonment

• In 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
  information
• A vulnerable older adult with cognitive
  impairments is put on a bus with a one-way ticket
  to another town or state
• A vulnerable older adult with cognitive
  impairments is left at a public building
• B. 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 obviousquestion for more info
• Examples
• Denying the vulnerable older adult a home
• Stealing a vulnerable older adults money or
  possessions
• Coercing a vulnerable older adult into signing
  contracts or assigning power of attorney
• Purchasing goods with a vulnerable older adults
  money for personal gain
• Coercing a vulnerable older adult into making
  changes in his/her will
• When a person entrusted to care for a vulnerable
  older adult fails to use available resources
  necessary to sustain/restore health and
  well-being of person
• Baker

37
Violation of Rights

• Not always obviousquestion for more info
• Examples
• Denial of older adults right to privacy
• Not allowing older adult to make own decisions
  regarding health care or personal matters
• Restricting interactions with others
• Forcible eviction and/or placement in a nursing
  home
• Elder abuse and neglect for EMS, EMSTopics.com,
  2007