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
• Stress
• Coping
• Anxiety
• Ethics
Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
•
Management of Care
17-23%
•
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
9-15%
•
6-12%
Basic Care and Comfort
6-12%
6-12%
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•
Pharmacological and Parenteral Therapies
12-18%
•
Reduction of Risk Potential
9-15%
•
Physiological Adaptation
11-17%
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:
Clinical Significance:
Foot pain
Cause of pain needs to be determined and pain management needed
Lack of intake of fluids
Look for signs of dehydration
Dried feces in perirectal areas and hasn’t had
a bath in three weeks
Poor hygiene, needs to be cleaned, infection risk
Pressure injury
Red, swollen scrotum
Likely irritation from feces/urine, needs to be cleaned and tended to
Redness in groin folds
Needs wound care
Skin tears
Fatigue
Malnourishment, patient needs proper nutrition
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Take glucose levels, determine if foot pain is related
Diabetes
RELEVANT Data from Social History:
Clinical Significance:
Widower, distant relationship with son, and
unreliable caretaker
Caretaker neglect
Risk for emotional health issues
Patient will need a better arrangement for long term care when
discharged
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 has been neglected and as a result is suffering from poor hygiene and poor skin integrity.
Malnutrition and dehydration may also pose problems for this patient. Currently, the priority should be cleaning the
patient and wound care.
2. Identify the differences between patient abuse and neglect. What are the most common findings that are
clinical RED FLAGS for the nurse?
Abuse is harm to the patient caused by the caretaker whether physical, emotional, or sexual. Neglect is indirect
harm caused from a lack of care. The red flags are that the patient’s wife is deceased, the son lives far away,
and the caretaker is unreliable.
3. What is the nurse's role in reporting suspected abuse, neglect, or exploitation?
The nurse is a mandatory reported and is obligated to report any suspected abuse, neglect, or exploitation regardless
of proof.
4.What additional information is needed by the nurse to clarify the dilemma? (NCLEX: Management of Care)
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When was the last time the patient’s son talked to the caretaker? How was the patient’s hygiene when the son last visited
him?
5.
What additional members of the healthcare team can be used in this situation? Why? (Management of Care)
Social work and a therapist should be used in this situation. A social worker can help find adequate care for the
patient when discharged. A therapist may be necessary to address any mental health concerns the patient may be
struggling with due to social isolation, the passing of his wife, and the neglect.
6. What does the nurse need to know to provide culturally competent care? (NCLEX: Management of Care)
The nurse should know his religious beliefs and if they will affect how they will affect the patient’s care. A
religious clergyman may be used instead of a therapist if appropriate. As culture often affects family values,
that may be important in determining how the patient will be cared for after discharge. Some cultures may
be uncomfortable with nursing homes and opt to take care of their elderly themselves.
7.
What is the nursing PRIORITY? (NCLEX: Management of Care)
The nursing priority is to take care of his physiologic needs, which includes hygiene, tending to wounds, and addressing
his malnutrition and dehydration.
8.
What are the PRIORITY nursing interventions? (NCLEX: Management of Care)
PRIORITY Nursing Interventions:
Rationale:
Hygiene
Wound care
Removing the feces is of upmost important to
prevent infection and improve the patient’s self
esteem
To prevent infection of the wound and keep the
pressure injury from increasing in size
Expected Outcome:
Prevent infection
Prevent infection
Hydration
To keep patient hydrated, will also help skin
turgor and help prevent future pressure injuries
Hydration, improved
skin turgor
Improving patient’s nutrition will bring back
his strength and improve wound healing
Help fatigue and
improve wound healing
Contact social worker to arrange adequate care
for the patient for discharge. Consult doctor for
a therapist to help patient’s emotional health
Adequate care will
prevent the patient
being neglected again.
Mental health services
can manage any
emotional issues
Nourishment
Contact social worker/therapist
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resulting from this and
patient’s family issues.
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)
Including the son in the patient’s care. Explaining to the patient the rationale for all treatments. Asking patient
about pain and managing it before it gets severe.
10. What is the expected response of the patient/family/caregiver (Management of Care)?
The patient and family are likely to be compliant. Since this resulted from negligence, the patient and
his family will be open to any medical care provided if they feel comfortable knowing he won’t be
neglected in our care.
11. What is the patient and/or family likely experiencing/feeling right now in this situation?
(Psychosocial Integrity/Basic Care and Comfort)
Anger towards the caregiver for neglecting the patient. The patient may be feeling embarrasses because of his lack of hygiene. The
son is most likely worried for his father or guilty because he left him in the care of someone that neglected him.
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)
Explain to the patient and their family member the rationale for every treatment and procedure. Encourage the patient to
share his emotional troubles with me. Involve the patient and his son in his care and show them how to change the
dressings for his wounds. Offer to consult social work to help them find adequate care.
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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?
The process of enlisting other disciplines in patient care
Keeping the family involved in the patient’s care.
What did you learn?
How will you apply learning caring for future patients?
The severity of the effects of negligence
Looking at the “big picture” by ensuring the patient has
adequate care once he returns home. Also, keeping in mind
how traumatic negligence can be and its effects on mental
health.
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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