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An individual's interpersonal relationship with family and community that determines use of resources and services in the maintenance of health are addressed in the social health system. Individuals are dependent on social support and interaction regardless of health status. Individuals who have chronic debilitating illness, who are very young or very old, or who have diminished cognitive abilities have a greater need for help from significant others including family, friends, social workers, social agencies, and community care facilities. Not all individuals are fortunate to receive positive, supportive care for any number of reasons. Limits may include the financial, intellectual, and emotional abilities of the support persons. ED nursing personnel frequently see patients who require a social work referral in order to sort out the complexities of matching care needs to resources available. Sometimes, because of inadequate coping styles and social supports, a patient presents to the ED with clinical signs and symptoms that are the result of abuse or neglect. The ED nurse should be aware of this potential and always assess the patient's social health system along with his or her biophysical health status. Case studies in this section are presentations of abuse that may occur with a child or an elder. The astute ED nurse will not limit his or her concerns to these two categories of patients. Middle-aged persons (male and female) often suffer from abuse and/or neglect and may be even more reluctant to share their social situation with health care workers because of shame over perceived lack of control or poor self-esteem.
For some patients extreme loneliness through chosen social isolation may be a cofactor in health status changes that prompt the need for medical care. This may be the result of a dysfunctional individual or family process.
| Family | Community |
| Abuse and neglect | culture |
| Coping | religion |
| Family planning | services |
| Finances | sexual relations |
| Home maintenance | social interaction |
| Parenting | social isolation |
| Process |
| Social Health System | |||
| Level I | Level II | Level III | Level IV |
| Referrals to social work: | |||
| Inadvertently left in hospital without transportation | |||
| Needs transportation to referral center does not meet criteria for ambulance transport and has no funds | |||
| Presenting for care because prolonged disease disability has exhausted supportive abilities of significant others | |||
| Removed from unacceptable home environment, i.e. condemned building; needs medical evaluation and social work referral | |||
| Appears to have been abused or PMH has high index of suspicion, or significant other appears to have abuse potential; client is receptive to counseling, will accept social work referral | Presents with injury secondary to abuse or neglect; plans to return to same environment; denies possible recurrence; does not accept psychodynamics | Sustained significant injury secondary to abuse; repeated episodes of abuse and return without counseling; or PMH of increasingly serious abuse or neglect | |
Laurel Ann Ault, RN, BS
Maurice is a 27-month-old black male brought to the emergency room at 1:50 PM by his mother and maternal grandmother. Maurice's mother states that Maurice has had the chickenpox for 4 days and a temperature, vomiting, and diarrhea since this morning. She further states that Maurice was well when she left for work this morning, leaving him in the care of her boyfriend. However, she was called home by her boyfriend when Maurice "suddenly became ill." Maurice has had no fever medication today.
On initial examination, Maurice is withdrawn and talking in monosyllables. He is lethargic, gray in color, with skin that is hot, dry, and of poor turgor. He is unable to stand, sit up, or hold his head up without assistance. His vita! signs are rectal temperature T-103.4°F, pulse-] 28, respirations-28, and BP 60 by palpation.
Triage Assessment, Acuity Level IV: BP < 90 mm Hg systolic. temperature > 102°F, lethargic.
Maurice is immediately placed in a treatment room. While being undressed, he is noted to have calamine lotion covering his entire body, even where there are no apparent pox lesions. Discolorations of the skin are also apparent under the calamine lotion.
An intravenous line of 5% dextrose and 20% normal saline is established, and bloods are drawn for a CBC with differential, SMA 7, amylase. bilirubin. ammonia level, and blood cultures. He is placed on Oz by cannula at 3 liters. A stool culture is obtained, and he is bagged for a urine specimen.
Further examination of Maurice, after initial emergency intervention and with the calamine lotion removed, reveals multiple ecchymotic lesions on his chest, abdomen, back, arms, bullocks, thighs, head, and neck. The ecchymotic areas vary in color ranging from red to darker red, to purple, yellow, and green. These lesions are noted to be linear and linear-looped in shape. There is also a healing linear-looped laceration to the upper left posterior thigh with redness and swelling of this thigh. The lesions vary in size from 1.2 x 1 cm to 1.5 x 8.5 cm.
On further interviewing as to the nature and possible cause of the lesions. Maurice's mother first stated she "didn't know" or notice any bruising, and then stated. Maybe it's because he likes to craw! under the bed.'' His mother did state that she does slap Maurice occasionally with an open hand, "but he has his clothes on. "
Maurice's grandmother stated she has seen Maurice being hit with a belt by his mother. She also stated that she visits everyday to "check on" Maurice. She last saw him yesterday but denies seeing any bruises.
Maurice's mother denies ever seeing her boyfriend strike Maurice. She also stales that the boyfriend told her that the bruise on Maurice's head occurred this morning when Maurice pulled a chair up to an unscreened window, climbed on the chair, and leaned out of the window. The boyfriend, fearing Maurice would fall out of the window, ran over, grabbed Maurice, lost his footing, and fell backward, with Maurice hitting his head on the stereo.
Maurice's mother is unmarried. She lives with her boyfriend. Maurice, and a 6 months--old daughter. Maurice's mother is employed in housekeeping at another hospital. The boyfriend is unemployed and is the father of the 6-month-oid daughter, but not of Maurice.
Maurice was admitted to the hospital with the diagnoses a/severe dehydration. rule out encephalitis secondary to varicella, gastroenteritis, and suspected child abuse and neglect.
This case study will discuss child abuse and neglect and as such will not address Maurice's medical problems.
TIP: Every child who presents in an emergency room, no matter what the presenting complaint, should be thoroughly examined to rule out possible abuse or neglect Current statistics on the instances of child abuse are considered minimums as many cases still go unrecognized and/or unreported.
Is the extent or nature of this injury consistent with the history as given or with the developmental age of the child?
The following categories describe current forms of abuse of children. Analysis of the pattern of the injury, as well as repeated injury to a child, are both significant signs for early recognition.
1. Bruises and welts. Studies indicate that bruises and welts are the most common manifestation of child abuse. The primary target zone for these injuries extends from the back of the neck to the back of the thighs. Assessment of bruises of various colors should be noted. Bruising can be dated through color changes: red-blue 1 to 2 weeks. blue-purple 3 to 5 weeks, green 6 to 8 weeks, and yellow-brown 8 to 10 weeks until resolution. If bruises are present and the caretaker(s) deny knowledge of them, inflicting them, or claim the child "bleeds or bruises easily," a bleeding disorder screen (PT, PTT. bleeding time. thrombin time. and platelet count) should be ordered by the physician.
TIP: There should be a high index of suspicion for child abuse when a child presents with bruising in various stages of resolution.
2. Multiple injuries. Multiple injuries consist of abrasions, contusions, and lacerations. Other indicators of a repeated pattern of injury to the child are contusions, welts, lacerations, and scar tissue injuries in multiple stages of healing, such as burns, scratches, lacerations, and bruises of various colors.
3. Wraparound injuries. This type of injury is caused by a flexible object such as a belt strap or extension cord. An extension cord leaves marks of a consistent thickness, while belt wounds leave both thin and wide marks in a looping fashion due to the centrifugal force that turns the belt.
4. Fractures. Evaluation of all cases of suspected child abuse should include long bone (trauma) x-rays, ordered by the physician. Long bone fractures that are torsion-induced are characterized as spiral fractures of the midshaft or evulsion fractures of the ankle, knee. wrist, or elbow joints. These fractures are usually the result of a twisting motion to the child by an adult. X-rays will also detect any previous untreated fractures, and if detected, will increase the probability that the child has been abused. Any child under the age of 5 in which abuse is suspected should have a trauma survey. Furthermore, a child under the age of 5 with a fracture, or a child with multiple fractures in various stages of healing, particularly under the age of 5. should prompt a high index of suspicion for abuse.
TIP: Bones of children under the age of five are elastic. Extreme force is required to cause fractures.
A more subtle indicator of abuse or neglect is evidence of learning disabilities or developmental delays, especially in language and fine motor skills, that cannot be attributed to a specific physical or psychological problem.
A psychological evaluation done 3 days after Maurice was admitted to the hospital revealed socially withdrawn behavior with receptive language skills at the 18 to 20 month level and expressive language skills at the 16 to 18 month level. There was no evidence of autistic like behavior or pervasive mental retardation. These behaviors are consistent with environmental deprivation.
When a diagnosis of abuse is suspected, the nurse should expedite the evaluation of the child. Cases of suspected child abuse should be given high priority. The reasoning is threefold: (1) There is the potential for the caretaker(s) to elope with the child before intervention can be initiated; (2) consultants may be necessary from other fields and arrangements for them to see the child should be made as quickly as possible: and (3) a child who has already been victimized is at risk of being secondarily victimized when placed in unfamiliar surroundings with unfamiliar people for inordinate amounts of time.
The nurse should provide pertinent information that will help the physician arrive at the correct diagnosis. In some instances the nurse may consider the diagnosis of child abuse before the physician. If the physician is reluctant to consider the diagnosis or thinks otherwise. the nurse should report it alone.
Once identified, the nurse should work with the physician to implement protocols on complete medical evaluation of the child. Detailed histories should be obtained from whatever caretaker presents in the emergency room with the child. If the child is old enough, abrief' history should be obtained from him or her. A lengthy interview may further traumatize the child. On physical exam, detailed notes should include site, shape, size, and color of injuries and whether there is the mark of an identifiable instrument or object.
If the parent refuses hospitalization for the child or a consultation, the nurse should notify the appropriate law enforcement agency. Each emergency room should have available in the unit a written copy of the law and the hospital's policy and procedure for child abuse patients.
The nurse should maintain a helping approach toward abusive parents. Feeling angry with abusive parents is natural, but expressing that anger is very damaging to parent cooperation. The nurse should acknowledge that most of these parents are lonely, frustrated, unloved. or otherwise needy people, who actually love their children but who have lashed out at them in anger. The nurse should help the emergency room staff remain supportive and therapeutic in these cases and ensure that the parents are kept informed of what is happening to their child at all times. Stress the emergency room staffs concern for the safety and well-being of their child.
The nurse should request a child protection team worker consultation. In general, psychosocial evaluations are done by the child protective service social worker. An inside hospital worker such as a social worker or child abuse liaison nurse with expertise in child abuse management should be consulted in all cases of abuse. A child abuse liaison nurse offers not only expertise in emergency medicine. but also in the subtleties of child abuse and neglect through training in this field.
The nurse, physician, or social worker should report suspected child abuse. Most states, by law, require a verbal report within 24 hr. and a written report within 48 hr in all cases of suspected abuse or neglect. This report is not contingent upon a definitive diagnosis of abuse or neglect, only the suspicion of it. This report is made to the local protective services agency. If a health care provider feels the child is in imminent danger of further harm if returned home, or if the care-takers) show signs of eloping with the child before the evaluation is completed, an order of shelter care may be obtained from protective services. This order ensures that the child cannot be removed from the hospital or the care of protective services until it is reasonably determined that the child is returning to a safe environment.
The nurse can provide alternative choices for maladaptive parents. Where appropriate, parents can be referred to organizations that provide classes in parenting skills, child growth and development, and stress management. The nurse should be familiar with what programs are available and make appropriate referrals based on this information.
The child who is the victim of abuse presents a major challenge to emergency room nurses. The child must be treated for the injuries sustained. The dysfunctional family unit must also be treated. The diagnoses must include not only the child, but the family, to establish optimal and comprehensive care.
Family Diagnoses
Diagnosis: Alteration in health maintenance related to inadequate therapeutic measures in illness or an unhealthy life-style, as evidenced by the delay in seeking medical attention by the caretaker (no fever medication given to the child, indications of long-term abuse)
Desired outcome: Family states an understanding of need for prompt medical care; family can state strategies learned from participation in parenting and stress management classes.
Diagnosis: Impaired home maintenance management related to inability of family members or caretakers to provide a safe home environment, as evidenced by multiple-injury pattern of presenting child; family denial of knowledge of presenting injuries
Desired outcome: Family states alternatives for child care and stress management; the child is provided a safe environment outside the family home until other resources can be initiated.
Diagnosis: Potential for injury to the child related to maturational age of child and ineffective coping pattern of mother; impaired home maintenance pattern of family
Desired outcome: The child experiences no further injury from caretaker(s).
Diagnosis: Alteration in parenting related to inability of the care-takers) to provide a constructive environment which nurtures the growth and development of the child, as evidenced by long-term abuse of the child; developmental delays of the child
Desired outcome: Family develops an awareness of the child's capabilities through parenting classes; parents verbalize acceptance of the child's right to be an individual.
Child Diagnoses
Diagnosis: Impaired physical mobility related to limited physical movement from pain, as evidenced by multiple contusions, laceration ,and swelling of left thigh; unable to sit, stand, or hold head up without assistance
Desired outcome: Child maintains or resumes full mobility.
Diagnosis: Powerlessness related to lack of personal control over certain events or situations, as evidenced by child's inability to protect or demand protection from abuse
Desired outcome: Child states that it is alright to say someone is hurting him; child states what are good touches and what are bad touches.
Diagnosis: Impairment of skin integrity related to contusions, laceration, and swelling of thigh with subsequent limited mobility
Desired outcome: The child's skin heals without complications.
Diagnosis: Disturbance in self-concept related to abusive parenting behavior in which child could experience or is at risk of experiencing a negative state in how he feels, thinks, or views himself, as evidenced by the feeling of abused children that "I must be bad or they wouldn't hurt me."
Desired outcome: The child states that he is not the guilty party; the child states an understanding of the fact that parents were unable to cope; the child develops a positive concept of himself.
Child abuse and neglect occur in all classes and cultures where economic instability, isolation, unprepared parenthood, social stress, parent self-hate, a misplaced sexual drive, and/or inability to cope with the pressures of everyday life are factors. Regardless of the motivation a child who is physically or mentally abused will be emotionally scarred for life, if the child survives.
Child abuse is a medical emergency, not just a social problem. Medical personnel have a unique opportunity to detect and report suspected abuse and neglect. Protection can then be provided for the child and help initiated for the parents. Again, it is not the responsibility of the ED personnel to obtain a definitive diagnosis of abuse or neglect. However, if there is any suspicion on the part of the provider. prompt care, documentation, and reporting are essential.
Ellerstein S: The cutaneous manifestations of child abuse and neglect. Am J Dis Child 1979; 133:906-909.
Helfer RE, Kempe CH: Child abuse and neglect. The family and the community, Cambridge: Ballinger, 1976.
Johnson C, Coury D: Bruising and hemophilia. Child Abuse Negl Int J (in press).
Johnson C, Showers J: Injury variables in child abuse. Child Abuse Negl 1985;9:207-215.
Lenoski D, Hunter S: Specific patterns of inflicted burn injuries. Trauma 1977; 17(11): 842-846.
Morris J et al: To report or not to report: physicians attitudes toward discipline and child abuse. Am J Disease Child 1985;139:194-197.
O’Hare AE, Eden OB: Bleeding disorders and non-accidental injury. Arch Dis Child 1985;59:860-864.
Rosenberg N et al, :Prediction of child abuse in an ambulatory setting. Pediatrics 1982; 70(6): 879-882.
U.S. National Center on Child Abuse and Neglect: Child abuse and neglect: The problem and its management, and overview of the problem. Washington, D.C.: U.S. Government Printing Office. 1976: 38-39.
U.S. National Center on Child Abuse and Neglect: Child abuse and neglect: The problem and its management. The community team and approach to case management and prevention. Washington, D.C. : U.S. Government Printing Office. 1976:96-99.
Wilson T: Estimation of the age of cutaneous contusions in child abuse. Pediatrics. 1977;72(5):750-752.
Carol A. Brown, MSW, LCSW
Mrs. B. presents to the ED with complaints of facial bruising and hip pain She states she had fallen at home while washing dishes. Mrs. B. is well known to the staff; she is evaluated often for episodes of chest pain and shortness of breath with no known etiology. She has a primary physician who monitors her medications and is informed of each of her visits. During this visit, Mrs. B. is noted to have several areas of ecchymoses covering her abdomen and upper right chest area. Second-degree burns are seen on her thighs and lower abdomen. Her vital signs are within normal limits. She describes a moderate amount of pain.
Triage Assessment. Acuity Level IV: second-degree burns of abdomen and thighs. Mrs. B. was taken immediately to the treatment area for management of her burns and evaluation of her other injuries. When Mrs. B. was determined to be stable and comfortable, the staff focused on her social history to determine more about the cause of her injuries.
Mrs. B. is a 79-year-old, white, divorced female who married at 16 years of age and conceived seven children. She moved to another state after her divorce. without the younger children (ages 10 and 12). Within 6 months, she returned to lake the children with her. including the daughter who is now an adult and cares for her. Mrs. B. is retired; she suffered an MI and a CVA 2 years ago.
Mrs. B. led an active life until her CVA. Her family then noticed a deterioration in her strength and a personality change. Mrs. B. became depressed and would become emotional over simple problems. Although rehabilitation had enabled her to gain strength to walk, she was unable to drive. This was a source of great anguish for Mrs. B.
On past visits, Mrs. B. had confided to the nursing staff that she was unhappy at home. She depended on her daughter more and more for assistance with bathing cleaning, and laundry. Mrs. B. said that she felt like a burden to her family. Herein leaves home for periods of time; her daughter works during the day, and Mrs. B ;.' unsupervised. Mrs. B. admitted her son drinks heavily and her daughter is upset over Mrs. B. 's grandson leaving home to join the military. Social work referrals had been offered, hut Mrs. B. refused.
During this visit, the nursing staff suspected abuse. The physician and primary nurse questioned Mrs. B. regarding her injuries. She became anxious and tearful requesting to be discharged. The primary nurse had established a relationship with Mrs. B. and explored the home situation further. Mrs. B. admitted that her daughter had thrown hot water at her because she could not rise from a chair. Also. Mrs. B had slipped during a bathing incident, and her daughter had struck her.
The primary nurse and physician concluded that Mrs. B. was in an unsafe environment. A referral was made to the ED social worker and contact was made with the daughter. Initially, the daughter denied the incidents but later admitted that she was overwhelmed. The social worker contacted protective services and the primary nurse discussed community supports and the need for education regarding care. The medical team admitted Mrs. B. to the hospital to allow respite for the daughter and to evaluate the patient's injuries further. Follow-up support would be made by the inpatient staff.
The number of elderly persons older than 75 years of age increases each year and has begun to constitute a significant percentage of the population. Innovative medical technology has increased the life span of those individuals over 65 years old. Yet this group presents with a new complex set of problems (1.2). The elderly are often frail and vulnerable to a higher incidence of disease and multiple health problems (2).
There is no standard definition for elder abuse. Definitions vary widely and lack uniformity because it encompasses a wide variety of behaviors, conditions, and circumstances (3). Prevalence has also been difficult to quantify because of the reluctance of the elderly and the caregivers to accept the seriousness of the problem. Victims are not likely to admit that their caregiver is responsible for their injuries or neglected condition (2,4). This makes it equally difficult for health care providers to assess an elder abuse case. Also. health care providers share in their own sense of denial of the problem, lack of awareness of the problem, ageism, and insufficient knowledge of supportive resources (2,4).
Studies reveal there are an estimated 500,000 to 2.5 million victims (3). The wide range can be attributed to the problems of definition. More recent surveys suggest that there are 1.5 million cases (2). Victims cross all races, socioeconomic status, and ethnic origin (4).
The Elder Abuse Prevention, Identification and Treatment Act of 1985 defines abuse as
. . . the willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or anguish; or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish, or mental illness; the term 'exploitation' means the illegal or improper act or process of a caretaker using the resources of an elder for monetary or personal benefit, profit, or gain: the term "neglect'means the failure to provide . . . the goods or services which are necessary to avoid physical harm, mental anguish or mental illness or the failure of a caregiver to provide such goods or services. The term 'physical harm' means bodily pain. injury, impairment or disease (5).
Three categories of elder abuse are defined for identification: physical harm, neglect, and mistreatment (3). Physical abuse is the deliberate physical contact that harms or intends to harm the individual. Neglect is the failure to provide necessary treatment and services for maintaining health and safety. Mistreatment is defined as the use of isolation, medications, or physical and chemical restraints with intent to harm. Mistreatment is most indicative of a psychological deficiency in the abuser (1,3,6).
National and state emphasis is placed on prevention and intervention with lawmakers amending the Older Americans Act to include definitions and funding. States now have mandatory reporting laws and reporting requirements. Legislation is still developing slowly. Many researchers feel elder abuse has emerged through the 1960's interest in child abuse and the 1970's interest in spouse abuse (7.8). Most of the reporting statutes include capabilities for immediate investigation and possible removal of the victim from the home in an emergency situation (4). Caseworkers from a protective services agency will conduct home assessments and will provide continuation of services and coordination for supportive measures. Inherent in this process is the patient's right to accept or refuse service. What is the victim's role in the decision-making process for his or her care and protection? Is the patient competent to make this decision? If yes, the victim has the right to refuse services. If there is a question of competency and ability to make rational decisions, measures will be taken to seek guardianship. These legal processes may protect and safeguard the person and property of the individual, but it is important to note that in some instances they can be tools of exploitation (6). Continued use of scientific studies to obtain empirical evidence of needs, prevalence, definition, and resources will validate and improve the care to the abused elderly.
Profiles of the victim and abuser are appearing in the literature that serve as valuable information for identifying and screening high-risk cases. A typically abused elder is over 75 years old, female, frail, and multiply dependent, who presents with several medical complaints. These medical problems impair the elder from caring for his or her own daily needs. Depression often occurs as the elder becomes more dependent. The individual requires assistance with activities of daily living. monitoring of medications, and management of finances (2.4.7).
The abuser is described as a family member, overwhelmed by the care demands and usually suffering from some type of stress. For example. nonresolution of a life crisis, substance abuse, unemployment. or poor family relationships (2,4,7). Percentages reveal that 40% are spouses of their victims: 50% are children or grandchildren (2.4).
Several theories have been postulated to explain the phenomenon of elder abuse. The impairment theory proposes that the elder is limited by a physical or mental disability that forces him or her to be dependent. The theory of psychopathology of the abuser contends that the abuser has personality traits or disorders that cause them to be abusive. Finally, the third theory is the stressed caregiver theory. Emphasis is placed on the burden of the caregiver to meet demands of the elder. Abuse will manifest itself as the internal pressures of frustration and resentment fuel and explode within the abuser. Not just one. but several of these theories can apply in one case (1).
Of note is the incidence of violence as a cyclical behavior pattern in the family. This pattern appears to be learned behavior that is accepted as a normal reaction to stress (1). The caretaker may have been abused as a child and may have observed other means of violence in the family (spouse abuse). In screening for abuse, it is important to realize that one family's mechanism for communicating may be a different exchange than what the health care provider expects or perceives to be normal. Further assessment and investigation is needed before a clear diagnosis can be made.
The detection of elder abuse is difficult. Victims most commonly present with complaints of medical problems (3.4). Psychological abuse appears more frequently than physical abuse: however, other studies reveal that psychological abuse with neglect will also often be accompanied by some type of physical abuse (3). Physical indicators are the most obvious and can range from signs of observable physical neglect to physical injury (2). Examples are unexplained injuries such as bruises, bums. and fractures: lack of supervision: constant hunger: poor hygiene: and unattended physical problems or medical needs (1). Neglect of a passive nature is the most common form of abuse (5,6). Neglect occurs when the caretaker fails to meet their obligation and the elder suffers from lack of food, attention, supervision, and abandonment.
Behavioral indicators provide information on the relationship between the caretaker and the elderly individual. An evasive or tearful response from an elderly person or no answer at all to questions regarding injury may be a clue to a risk situation (9). Excessive fear or paranoia in the presence of the caretaker may indicate an abusive situation (2.4). The caretaker's behavior is an alert to how the elderly person is treated. The nurse should carefully watch the interaction between the caretaker and elder. Although abusive language is normal in some families, it is important to follow-up on suspicions.
If the caretaker exhibits an obsession with control, reluctance for the elder to be evaluated in private, hostility toward the elder, improbable explanations for injuries, frustration at the burdens of caring for the individual, and has provided care for an extended length of time. abuse may be occurring. If the caretaker describes other problems that are causing stress such as illness, family dysfunction, unemployment, or alcohol or drug abuse, then the elder may be at risk (2.4.9).
To make a complete assessment, access to the home is necessary. Since this is not possible by nurses who work in acute care settings such as the ED. questions can be asked to determine if environmental indicators are present. For example, locks on the elder's bedroom door. kitchen, and bathroom are signs. Where is the patient's bedroom in relation to other family members? Is there access to the phone? Are there steps in the home that act as a barrier (2,4)° If there is need, does the elder have access to ambulation aids? Does the elder take a lot of medication, especially for sleep (4)?
Mrs. B. presented with several of these indicators. The combination of Mrs. B.'s bruising to the face, abdomen, and chest area plus the untreated burns were alert signs for the nurse. Mrs. B.'s frequent visits to the ED with complaints of unfounded chest pain and shortness of breath also were indicators. She lived at home with her children, and her care demands had exceeded the family's ability to provide care for her. The son had begun to leave the home, and supervision of care was placed upon the daughter. The son had begun to drink heavily: the daughter's son had left home and she was grieving the loss of that relationship. Mrs. B. had several injuries evident of trauma that had not received medical care. Assessment and recognition of these indicators assisted the nursing staff in diagnosing potential abuse which initiated further intervention.
Particular questions to address that would be helpful in making a diagnosis of abuse are listed below:
Observations:
1. How severe is the patient's condition? Consider internal injuries.
2. Is the family cooperative with staff?
3. How do the patient and caregiver interact?
4. Is the home safe for the elder to return to?
5. How did the patient respond to talking to someone else?
Questions:
1. How did you receive your bruises?
2. When did this incident occur?
3. Why did you not seek medical care?
4. Can you ambulate well at home? Can you perform activities of daily living?
5. Were you alone when this happened? Who takes care of you?
6. Do you live alone or spend a lot of time alone?
7. Could your situation at home be improved?
8. Are there problems with your family? Illness? Drugs?
9. How do you think your caregiver feels about you?
10. Where do you go for routine medical care and follow-up?
11. Would your family be upset to know you are here and talking to me?
In the case of Mrs. B., the nurse did follow this guideline of questions. Information obtained allowed the staff to prepare a safe plan for Mrs. B. and her care.
Nursing diagnoses that are pertinent to the family cluster that suggest potential for abuse are those of relating and choosing. There are diagnoses pertinent to the family dynamics at large and those that relate to the individual victim of abuse.
Diagnosis: Altered family processes related to the change in family roles of the patient's son and daughter because of the patient's poor health.
Desired outcome: The patient's son and daughter will demonstrate more positive coping strategies when faced with stressful situations: the patient's son and daughter will acknowledge change in family roles and will participate in decisions regarding follow-up care.
Diagnosis: Ineffective, compromised family coping related to insufficient, ineffective, and compromised support, comfort, assistance, and encouragement from the son and daughter to the mother to manage and master adaptive tasks related to her current health status
Desired outcome: The patient's son and daughter will assist the patient to achieve maximum potential in performing self-care activities; the son and daughter will acknowledge needs of the patient and needs of the family as a unit; the family will participate in the treatment plan.
Diagnosis: Self-esteem disturbance of the patient related to changes in health status, loss of independence, and dysfunctional behavior of the son and daughter.
Desired outcome: The patient will verbalize more optimistic feelings of worth and seek to maximize her potential in her current health state.
Diagnosis: Social isolation of the patient related to change in health status and dysfunctional behaviors of the son and daughter.
Desired outcome: The patient and family will seek means to integrate the patient into social settings suited to current health state. Son and daughter will develop means to actively include patient in family affairs.
Diagnosis: Impaired home maintenance management related to patient's decreased motor functioning and ineffective support mechanisms provided by the daughter and son.
Desired outcome: The patient will be assisted by her son and daughter to achieve her potential in managing tasks at home independently. as possible; the patient's daughter and son will agree on ways to effectively cope with increased demands related to patient's home care.
Diagnosis: Powerlessness of patient related to patient's pattern of helplessness from change in health status and feeling of dependence on her son and daughter for care.
Desired outcome: The patient will describe feeling in control. The patient will participate in decision making regarding her plan of care; the patient will share her feelings with her son and daughter.
Once abuse and/or neglect is identified, interventions will depend on the nature of the abuse or neglect, the setting, and the amount of information available (2). Nurses, physicians, social workers, and law enforcement personnel are the first line of defense for victims (6). Of all medical personnel, the nurse is most likely to be present when an elder needs help in sorting feelings. The nurse's activities can create an atmosphere where the patient feels free to reveal difficulties at home (10).
Complete information should be obtained regarding the patient's physical condition and documented specifically in the medical record (8). It is best to talk to the patient in private. Discuss with the patient the concerns and the willingness of staff to help improve the situation (8). It is important to recognize the needs of both the victim and caretaker: intervention must be directed at the well-being of the victim, but also to the coping ability of the abuser (8). The nurse should help the patient and family develop a plan that will improve the patient's care in the home or make alternative living arrangements. Focus should be on practical issues: what does the patient want? The nurse should provide the necessary psychosocial supports for the abuser with emphasis on skills training and self-managing training for the elderly (2.4.8).
A referral must be made to the welfare or social services agency responsible for follow-up. A protective services agency can initiate legal action against the abuser if necessary or provide interventions within the home environment (8). Interventions may include exploring alternative living arrangements, provision of in-home supports, supportive counseling, education and skills training for the abuser. and continued case management. Home health nurses are in a unique position to observe and monitor families in their home environment. They may be the first to identify a risk situation (9).
The nurse, in the case of Mrs. B., interviewed her separately from the daughter and consulted with the physician for further assessment. The nurse explored the home situation in a safe environment for the patient to verbalize her feelings. Mrs. B. began to present a clear profile of an abused elder. A referral was made to the ED social worker who referred the case to protective services and the inpatient worker for case management. The nurse responded to the needs of the daughter: continued interventions would be directed toward stabilizing the family and providing a safe environment for Mrs. B.
Medical caretakers in acute-care settings are confronted with the increasing social problem of elder abuse. No one provider or profession should be responsible for the identification and management of these cases. A multidisciplinary team should be used whenever possible. The team can include physicians, nurses, social workers, attorneys, and psychiatrists. Specified goals are for coordination, education, diagnosis. treatment, consultation, and prevention (1,2.3). Teams will van. because of local resources and the structure of the institution. Since the elderly are more difficult to care for, physicians will have to spend more time and patience to provide treatment. Social workers are challenged to uphold the rights of the elderly yet adhere to the requirements of the legal system. Many of the issues involved with elder abuse are of a social nature. Nurses are in a position to be present when the patient is most vulnerable and willing to sort out their feelings. Establishing a reputation as a helping professional allows the nurse the advantage of performing ongoing assessments. Nurses are usually the first responder to care, whether it is through triage or acute care.
The case of Mrs. B. would be appropriate for staff case conference. Increasing awareness among nursing staff of elder abuse would provide knowledge and understanding when other cases present.