Welcome, today's topic that falls under
the category of Psychosocial Integrity
i am gonna talk a little bit
about Abuse and Neglect.
And if this is a area that you
forgotten you wanna go back
and review your pediatrics
and your general ontology.
Those are the categories that usually
think of falling under abuse and neglect.
So we are gonna do a fast review.
But again if this is a topic that you
remember a lot about, you wanna go back
and review; because, this falls under safety as well.
And make you sure that we recognize our
patients whether they are safe or not.
And whether we recognize for sending
them back into a safe environment.
So the overview again, this topic
falls under psychosocial integrity.
As you know in that NCLEX, it's divided
into different categories
and abuse and neglect
falls under psychosocial.
So what are our outcomes? That we are gonna
be talking about today. First of all
you need to make sure that you
can assess your patients
and be able to recognize potential or
actual physical abuse and neglect.
Need to identify those risk factors
and also use the nursing process to be
able to work through with your patient.
That might be at risk or actually
suffering from abuse and neglect.
So let's start off with
a typical NCLEX question.
A primary prevention measure that
should be implemented by a nurse
when working with patients who
are at risk for elder abuse is:
A. Reporting a case to
law enforcement officials.
B. Referring caregivers
to community resources.
C. Offering counseling to the victim.
Or D. Providing the elder
with hotline numbers.
Again we are looking
at primary prevention.
So make sure you are
reading your question well.
and know the difference between primary,
secondary and tertiary prevention.
And the answer to this question would be B. Referring
the caregivers to community resources
would be proactive and stopping
or preventing abuse and neglect.
So let's just generally talk
about abuse and neglect.
Abuse can be physical,
sexual and emotional abuse.
Again be thinking about children
that you have studied in pediatrics
so that you have
seen out on the floor.
But also don't forget about your
elders in the nursing homes,
coming into clinics, that you
have seen out an about at
senior centers, community areas
where elderly people hangout.
Neglect includes physical
emotional neglect. Again
we gonna talk about
adults and we gonna
talk about children.
But we thinking through your mind,
"how you would be able to spot that patient?".
If they came into the ER or came
into your physician's office,
Would you be able to
pick up on those clues?
You should be familiar with your state's
laws wherever you are practicing.
Make sure you that know what
your laws are about reporting
about follow through. What documentation
you need and who you call?
And then nurses must be
able to identify risk factors.
All the time looking at caregivers whether they
be a doctor givers whether they be parents,
whether they be guardians. But can
you pick up on sudden signs?
That your patient
may be telling you,
or may be indirectly telling you.
Or the caregivers may
be giving you signs
that they don't even know they are giving.
And are you able to pick up on those?
So let's start with
Physical Abusing Pediatrics.
Who are the risk factors?
What are the risk factors?
We know that we are looking
at the personality types
and we are looking at
And one of the circumstances that we
are looking at is parents: that are young
and immature. Your teenage parents
younger parents that may be didn't get
to finish high school, or finish college.
Look at those parents. Parents
with unemotional needs:
Again if they weren't emotionally
taking care of as children
you can kind of pick out those people that are
always wanting the attention to themselves.
Economics plays a big part.
But don't always assume that
low social-economics are the abusers; because,
we also know that higher economic
families also have
abusing their families.
Domestic violence: Always be watching
for signs and symptoms of that.
Parental mental health issues:
We have a lot of people
that are undiagnosed
mental health issues. So again be looking
for signs and symptoms in those parents
and how they are treating their children.
Substance abuse is always at the top.
Whether it's adult abuse or whether it's
pediatric abuse. Again people that are
abusing on substances whether be
alcohol, whether be drugs are more prone
to cause physical abuse to their children.
And then, chronically ill children.
Be thinking about your families
that are taking care of
chronically ill children, special needs children,
and the stress that goes along with that.
Not only the physical and
emotional but financial stress.
Keep an eye on those
families as well.
Because we know that just
the stress can lead to abuse.
Children with ADHD or ODD:
Again remember children
cause stress to the family
be looking for signs and symptoms
of an inappropriate discipline.
Or may be where the
parent just had it.
Again if you pick up on
those signs and symptoms
we can keep our children safe.
and recognize them at
a earlier risk/time.
Another risk factor is when there is
no biological father present or
mom has brought in a boyfriend.
It doesn't take much to
watch the news to know
that these two risk factors
usually play a part
in abuse. So again be asking about
the socialness of the family.
Who is with the children? Who watches the
children? Is mom at home? Is the boyfriend
taking care of children a lot?
Again not necessarily meaning
that abuse is going on
but as a nurse if you are always keeping
that in the back of your mind
you been able to pick up on those
signs and symptoms a lot faster.
So assessment clues. How do i know?
Most of times kids aren't necessarily
gonna just come right out and tell you
elders that are being abuse aren't
just necessarily gonna come out
tell you out of fears and embarrassment.
So as a nurse review the signs of what
you are looking for in these kids.
So delay in seeking medical care.
You have a patient that comes
in and they are very very
checking you. If something is telling you
"why didn't the parents bring them in earlier?"
Make a note of that and
do some investigation.
If they have their
stories that don't match up,
is what i am trying to say.
You know moms tell a story. Dad tells
a story. The child tells a story
When those stories don't match
up as to how injuries happened.
Or why they didn't come
to the hospital earlier?
Make sure you document that
and take note of that.
What about frequent injuries?
Be looking at old bruises, new bruises.
Is there a pattern of how many
times they have been in the ER?
Is there a pattern by many times they
have been to the doctor's offices
with stitches and those kind of things?
And then again look at the
reasons. Go back and read
histories as to what the reasons
why its behind the injury.
Withdrawn children: We known most
children are afraid of strangers
and that's the way it should be. But
you should be able to tell as a nurse
on whether a child is
just being withdrawn?
Or whether they are afraid because
you are a medical person?
Be looking at those kids who sleep up
into the corner. They don't talk. They
coward down when the parents talk to them
and pick up on those sings as well.
Non-coping behaviors in children:
You have elder children that they
have temper tantrum they
kept in-scream. But might be an
inappropriate for what's going on.
Take not of those situations as well.
Children that won't look at their
parents when they are with them,
don't make eye contact with the parents.
They don't look to
their parents for comfort.
Those are all signs and symptoms.
Again we talked about bruises,
looking for old and new bruises.
Suspicious burns or suspicious
pattern injuries: Again
i know you learned in
pediatric to look for
patterns of injury and
does it look like something.
Again and being able to talk
to the child and being able
to investigate what's going on.
We will help that child and
we may be saving their lives.
So being able to pick up on
those sudden signs and symptoms
as a nurse is our responsibility.
And then looking at when you talking
about, you know, "what happened?".
Is the parent always
blaming another child?
And again we all know
that children play.
Children bite each other.
But you should be able to pick up on
to the subtleties of what
the parents saying and
what the child saying.
And to be to do a
good nursing assessment
and be able to document everything so that you
have a good record of what's going on.
Now reflect to elders.
Again a lot times, a lot of the
circumstances are the same. You have
caregivers. You may be a talking
care of elderly parents
or grandparents who may be
have dementia or alzheimers.
And so a lot of is I
taking care of children
and sometimes the elder don't know that they
are being abused; because, they have dementia
or too embarrassed to admit that
a family member is abusing them.
So a lot of times when you
are looking at abused elders
a lot of times they
were abusers themseles.
And you have caregivers
telling stories about
"how their mom or their dad used to abuse
them". Again look for those kinds of patterns.
Abused elders are usually vulnerable.
We know as we get older
our bodies get weaker
and so its a little bit easier
for a younger caregiver
to overpower for a older person.
So be watching for those
signs and symptoms as well.
Not only physically, emotional,
mentally and financially.
Caregiver stress plays a
huge part. As nurses we know
when we take care of patients
with dementia or alzheimer's
it can be a struggle. It can be physically
and emotionally overwhelming.
If these people are taking care at
their home, be thinking about their
caregiver and "do their caregivers
ever get rest at time?"
If they don't, then be looking as social
services and people that can step
in and may be give them a break.
We know how tiring 24/7
is taking care of a patient
who is totally incapacitated
whether physically or mentally.
So be watching those
people, be asking a lot of
questions and be picking
up on signs and symptoms.
financial. Again as nurses
we don't always know when
financial abuse is going on.
But you can pick up on signs like may
be prescriptions aren't being filled.
May be doctor's visit
aren't being paid full or
little things like that, that might
be a clue to alert somebody who
can look into the backgrounds
of what going on by naturally.
Psychological, physical abuse: Again,
you known are they
degrading their parents?
Or they you know, yelling at them for being in
corner? Are they degrading them for being in corner?
Those are signs and symptoms that you can pick up
on but may be the stress is too much.
May be there has been abused or
may be it's leading to abuse.
And then risk factors.
Again the victims
are usually poor health.
Elderly people who may
be are in wheelchairs.
They can't walk on their own.
They can't drive on their own.
May be they can't see very well.
Those patients are all at risk; because,
they are physically vulnerable.
You also has people
that are isolated.
If they can't get out on
about and they are home a lot
then no body is gonna be able to catch
the injuries and those kinds of
things and be watching those patients.
And may be you can set
up like a home care visits.
And then impaired memory
You know sometimes the
caregivers will use that
their mother or father can't remember.
So they must be making up stories.
Again if things aren't matching up
those are the things that as a nurses we
should be using our assessment skills.
And then mental illness.
or alzheimer's, those kinds of illnesses
where the persons can't
tell you what's going on.
And then in the abuser, again,
just like with children
substance abuse, stressful life events,
the fact that you are stuck as a
caregiver taking care of your elder patient
or elder parent or
grandparent whoever it is.
Is that causing stress? Is
that causing financial stress?
All of those can lead to abuse.
So but how we gonna know?
If we have a patient, think about your
patient that has dementia or alzheimer's
they are not gonna be able to
come right out and tell you.
So what are some of the assessments
that you are going to see?
Increase agitation is a big one.
If you have a patient that is
increasingly being agitated
or is more agitated when
their caregivers are around.
Paying attention to that.
Looking at those signs and
symptoms and documenting that.
Anger: Anger for no reason. Again
this may be the only way that
the elder has to communicate.
So be picking up on those signs and
don't just automatically think that
it's part of their disease process.
Fear: Again if they are afraid
of being hurt. Afraid of being hit.
Afraid of being yelled out.
Do they coward away when
the caregivers comes in?
Watch again just like with pediatrics.
You watch the behavior
when the caregiver is in the room.
Poor eye contain: Again
just like with pediatrics
if they don't wanna make eye contact, afraid
of being yelled out or afraid of being hit.
Again watching that even if the patient,
again, can't tell you what's going on.
And then depression.
Sometimes people think
their older people, a lot of them are
depressed because of stuck at home.
Don't just overlook
depression as being as
symptoms of just getting old.
Look at and ask questions about family's
situations. Who is taking care of them?
Do they get to go out to the store?
Those kinds of things, may
be you can find a pattern
as a nurse to be able to bring it
to social services attention.
And then weight loss is a sign, if they are not
getting nutrients that they should be getting.
If they are very dehydrated because
they are not getting water.
Again if they are depending
on somebody else to
get them their food to fix their
food. And that is happening
then those would
be signs and symptoms
that you would be picking up on them may be
have nothing to do with the disease process.
Again dehydration that I just mentioned.
Unexplained injuries: Again
we know older people come in with broken
hips. But if the stories don't match
just like with pediatrics, we wanna make sure
that we are asking the right questions.
Noncompliance with medical plan of care: Again
a lot of times excuses will be used
about money and insurance. But if
patients aren't showing
up for doctors appointments,
for consults, that are not
getting prescriptions filled.
Again as a nurse I may not be able
to directly effect that.
But i know people who can.
And if I do my assessment and I document, I
can get social services case management involved.
So severe skin breakdown is a big one. We
know as nurses will watching that all the
time in hospitals and nursing homes.
Watching the skin breakdown.
Once the patient goes home
with the family as it doing the same vigorous
case that we do at the hospital
the patient gonna get skin breakdown.
So if they come into the
hospital and they have
skin tears and they have pressure
ulcers, be asking those
Are they getting around?
Are they getting turned? And should
home healthcare becoming into assess?
Recent changes in the will:
Again as a nurse i don't ask people
about their will. But again
you can hear people talking. Those are all things
that you need to educate your patient about.
Educate other people that
may be aren't directly
involved in their care. To be watching for
those signs and symptoms of financial abuse.
Unwillingness to spend money
on the elder: Again if
they come into the hospital
at the doctor's office and
all close and they vague
it and they don't have
you know a coat. All those are
kind of things to ask again.
You can asking your
assessment. But to be aware
of those out signs of abuse.
So after assessment, as nurses
we look at nursing diagnosis.
So what are some of the more common
or the inverse nursing diagnosis that come into
mind when we talk about the elder abuse and neglect.
Or risk for injury should be at the top.
That is what we are doing. We preventing injuries.
So when we look at all risk for injuries
in our diagnosis and in our
planning and our goal setting.
Hopefully we can catch some of
those things before they happen.
Fear should be at the top as well.
Patient shouldn't be in fear of
the people that are talking care of.
But what about powerlessness?
If I am elderly and I physically
cannot and defend myself.
There is a risk of powerlessness.
Of risk of "i can't
do anything about it."
So what kind of goals what
I set for this patient?
What about spiritual distress?
Don't forget spiritual distress
many time the way
we think about things
and even our powerlessness. If
we can't have our spiritual needs
taking care of. If we
are not taking the church
or offer prayer or whatever
we feel is our higher being
that can have a definite effect on our
mental well being and our
emotional well being as well.
And what about altered family
processes? That's another big one.
If it's a family member
that is abusing we definitely
have altered family
processes that we need to be
looking for goal
setting and interventions.
That we can use to help
with that altered family.
And then changes in role strain in
caregiver role strain. Again as we talked about
parents-grandchildren don't ask
for the situations that they are put in.
And so right there it causes
caregiver role strain. So what
can we do as nurses? As we
developing our care plans
and we are developing our nurses
diagnosis and our goals.
What we can do to eliminate some of
that stress that might lead to abuse?
When we looking at physical neglect
for pediatrics. This goes a
lot as well with the older adult.
Poor hygiene is at the top. Many times
children are brought into the ERO, into
the physician's office that are filthy
and that doesn't always mean
that they have been abused.
That mean may be they are outside
playing when they got the injury.
But taking note of the hygiene of
the child when they come in.
Inadequately dressed for the weather:
Most of the times we see
this in a colder areas
i mean in the winter time they come
in and they don't have cloths on
or they don't have adequate shoes.
Again we are looking at the
kid decided to do that or
do the parents not provide.
Failure to thrive: Go back and
look at you the pediatric book.
We know that there is inorganic
and organic failure to thrive.
Organic failure to thrive is when there
is something physical. But inorganic would be
parents not providing the
nutrients for the child.
We talk a lot about formula and
mixing formula and do the parent
water down the formula.
And what kind effect will
that have on the infant?
Again if it is an inorganic
reason, be assessing that
and picking up on that
and documenting that.
Why can the child not setup?
Why can the child not roll over?
Again we don't automatically assume
that it's because of neglect.
But we need to be finding out what is going on.
And we do that by good assessment skills
good nursing diagnosis
And then constant hunger. Again looking at
the children if they are always hungry.
Is it because they are going through a grow spurt?
Or is it because the nutrients needs aren't being met?
Constant fatigue: Usually
we hear about this with
schoolish children. The teachers call and say
that "they are always falling asleep in class."
Again if the parents come to you and say
"i don't know they are always falling asleep?"
You do a good assessment. Is there
something else going on? Or
are they being kept at the
night for certain reasons?
Or are they afraid to go to sleep?
May be because of sexual abuse.
So again being able to
ask the right questions to
the right people and then documenting.
Destruction of valuable: Again that's where
the anger come in. Be watching for that.
Unattained medical needs: Again,
have a child that has asthma
if they are not getting their inhalers filled.
If they are not getting
their steroids filled.
Again be asking those questions
as to why. Those could
be signs of neglect.
Frequently left unsupervised
for long periods of time:
We hear about this in the news where children
are found after days of being left alone.
Again a lot of times children will
tell you this in the assessment
if you get report
and you gain redressed.
Infants with balds spots.
Be looking for those
You know do they lay on one
spot for long period of time.
Be watching for head banging. Be
watching for teeth little eroded.
Be watching for lack of interest
or no bonding with the parents.
Again, as a nurse, sometimes these
kids are calling out and needing.
Somebody to notice. They don't
know how to get your attention
But they are hoping that somebody notices these
things and as nurses sometimes we are the first line.
So make sure you use good nursing
assessment skills, diagnosis skills
and know who you need to report to.
Now talk about sexual and emotional abuse.
Again what kind of signs,
most of these can be apply
to the elder as well as the pediatric.
And we start with the genital pain.
A lot of times kids won't tell you.
But they can show you sings and symptoms.
Sexually transmitted diseases: Again in the child
should never happen and in the elderly adult
specially if they are nursing homes or their home
it probably would never happens.
So again why they are having
sexual transmitted diseases.
Are they getting treated?
And then looking at
the assessment and diagnosis.
Difficultly walking or sitting, this is
for the pediatric patient. Again
may be they are not walking or sitting
because of sexual abuse. May be
it isn't a developmental probelm.
Frequent urinary tract infection, watching for that.
Sometimes parents will say "oh, they just
always have urinary tract infections"
But again as a nurse can you
pick up on that sign and symptom
and investigate as to "why?"
Is it something physical? Or
is it some sort of abuse?
Stained or bloody undergarments: Specially when they
come into the ER or into
the physician's office.
Seductive behavior at a young age:
Sometimes we catch that in a hospital
after they have been there for a day or
two for may be for other illness
and we start noticing
that the behavior is odd
compared to may be another
child of the same age.
And being able to pick up on that.
Excessive masturbation: Again in children
being able to pick up on
that. Or if you hear of
family member talking about it or
sibling talking about it.
Again being able to pick up and understand that
those are all signs and symptoms of sexual abuse.
And then excessive
preoccupation with sex:
Again 3rd graders, 2nd graders, kindergarten, all
shouldn't be talking about sex. Again sometimes you
hear them talking about when their parents aren't around.
Again as a nurse being able to understand
what growth and developments
stage the child is at. And what's signs
and symptoms are normal and abnormal
and looking for signs of sexual abuse.
Domestic abuse: Again remembering
that a lot of times this
is surrounded by fear.
Whether its female or male or whether its
the children that are involved.
But being able to pick up
on signs and symptoms.
Being able to do thorough assessment
and being able to ask
for right question to
pick up on domestic abuse.
So when looking at nursing -
an Identify assessment clues.
And what do i need to do?
Who do i need to report to?
You need to know that whether it's in the policies
or procedure. Whether its your state law?
But i need to report
to the required agency.
As a nurse i am
required to report
so knowing when do i report and
what are the laws for that.
Keep the patient safe.
Again that is our ultimate responsibility.
We are patient's advocates.
So keeping them safe and
doing whatever we can
to make sure that we are not
sending the patient back into
a environment that might be harmful.
Be an advocate: Again be looking for questions
where you are the patient advocate.
and remember that's all the
patient has is the nurse.
And so answers question to make
sure that you are protecting them.
And that you are being an advocate.
And then know who your resources are
and educate families, educate
caregivers., educate children
on the signs and symptoms of abuse.
if a child or if an adult has been abused
no mater what the kind of abuse is,
being able to pick up on
as a nurse. As to what
kind of response have been afterwards?
Pain is a huge one.
Lot of times people will come in and they
have pain in and they can't describe it.
And as nurse its our job
to make sure that we
figure where the pain is
and what's causing it.
The only way we can do that is
our good assessment skills.
Ineffective individual coping. Again
if they are coping one way or another.
Whether its trowing temper
tantrum? Whether its denial.
Making sure that we
are picking up on now.
Altered protection: Again
are we sending our patients back
home and in an environment
that is going to cause harm or is there
a way that they can be protected?
Personal identity disturbance: This
is huge specially for elders
if they are being abused by loved ones.
You is there identity being
taken away from them.
Sleep pattern disturbances are huge.
May be patients don't know that why they are not
getting the sleep that they were getting.
But again asking the right questions.
Ineffective family coping:
Whenever there is abuse it always affects
the whole family who ever the
family is. So make sure that you are looking at
siblings and other family members as well.
Altered parenting. Again a
lot of time with abuse
it is the parents don't know. They
are not educated on how to
careful their children. So altered parenting is
definitely a nursing diagnosis that we need to look at.
And as a nurse i may not directly
be able to affect that.
That i can hook them up with social
services and case management they can.
And then its social isolation/withdrawal.
The more somebody is isolated,
the risk they are for abuse.
And then risk for altered abuse
response patterns. Again
We don't want the abuse to continue.
So what can i do as a nurse? I can assess
and i can document, and
i can use my skills.
to educate and to prevent.
So in closing,
Abuse and neglect is not a topic
that we like to talk about
as a nurses. But again a lot of
time we are on the front lines.
We are the ones that catch it.
We are the ones that bring into light
and when our patients can't.
So make sure you are looking again at
pediatric books and dermatology books.
And we are reviewing those signs and symptoms so
if that patient sitting in front of you
that you will be to care for them. And you
will be able to protect them.
And you will be able to answer those
question on NCLEX. Good luck.