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Abuse and Neglect

by Diana Shenefield, PhD
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    00:01 Welcome, today's topic that falls under the category of Psychosocial Integrity i am gonna talk a little bit about Abuse and Neglect.

    00:09 And if this is a area that you forgotten you wanna go back and review your pediatrics and your general ontology.

    00:16 Those are the categories that usually think of falling under abuse and neglect.

    00:20 So we are gonna do a fast review.

    00:23 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.

    00:30 And make you sure that we recognize our patients whether they are safe or not.

    00:34 And whether we recognize for sending them back into a safe environment.

    00:38 So the overview again, this topic falls under psychosocial integrity.

    00:43 As you know in that NCLEX, it's divided into different categories and abuse and neglect falls under psychosocial.

    00:50 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.

    01:02 Need to identify those risk factors and also use the nursing process to be able to work through with your patient.

    01:10 That might be at risk or actually suffering from abuse and neglect.

    01:15 So let's start off with a typical NCLEX question.

    01:18 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.

    01:31 B. Referring caregivers to community resources.

    01:35 C. Offering counseling to the victim.

    01:38 Or D. Providing the elder with hotline numbers.

    01:42 Again we are looking at primary prevention.

    01:45 So make sure you are reading your question well.

    01:48 and know the difference between primary, secondary and tertiary prevention.

    01:52 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.

    02:04 So let's just generally talk about abuse and neglect.

    02:07 Abuse can be physical, sexual and emotional abuse.

    02:12 Again be thinking about children that you have studied in pediatrics so that you have seen out on the floor.

    02:18 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.

    02:32 Neglect includes physical emotional neglect. Again we gonna talk about adults and we gonna talk about children.

    02:40 But we thinking through your mind, "how you would be able to spot that patient?".

    02:44 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.

    02:55 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.

    03:08 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.

    03:22 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.

    03:34 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 different circumstances.

    03:43 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.

    03:56 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.

    04:10 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.

    04:22 Domestic violence: Always be watching for signs and symptoms of that.

    04:27 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.

    04:40 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.

    04:55 And then, chronically ill children.

    04:57 Be thinking about your families that are taking care of chronically ill children, special needs children, and the stress that goes along with that.

    05:05 Not only the physical and emotional but financial stress.

    05:08 Keep an eye on those families as well.

    05:11 Because we know that just the stress can lead to abuse.

    05:15 Children with ADHD or ODD: Again remember children that behaviorally cause stress to the family be looking for signs and symptoms of an inappropriate discipline.

    05:28 Or may be where the parent just had it.

    05:31 Again if you pick up on those signs and symptoms we can keep our children safe.

    05:36 and recognize them at a earlier risk/time.

    05:42 Another risk factor is when there is no biological father present or mom has brought in a boyfriend.

    05:49 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.

    06:00 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.

    06:18 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.

    06:32 So as a nurse review the signs of what you are looking for in these kids.

    06:37 So delay in seeking medical care.

    06:39 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.

    06:50 If they have their stories that don't match up, is what i am trying to say.

    06:57 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.

    07:04 Or why they didn't come to the hospital earlier? Make sure you document that and take note of that.

    07:10 What about frequent injuries? Be looking at old bruises, new bruises.

    07:16 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.

    07:33 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.

    07:59 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.

    08:09 Take not of those situations as well.

    08:12 Children that won't look at their parents when they are with them, don't make eye contact with the parents.

    08:17 They don't look to their parents for comfort.

    08:20 Those are all signs and symptoms.

    08:23 Again we talked about bruises, looking for old and new bruises.

    08:27 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.

    08:38 Again and being able to talk to the child and being able to investigate what's going on.

    08:44 We will help that child and we may be saving their lives.

    08:47 So being able to pick up on those sudden signs and symptoms as a nurse is our responsibility.

    08:54 And then looking at when you talking about, you know, "what happened?".

    08:58 Is the parent always blaming another child? And again we all know that children play.

    09:05 Children bite each other.

    09:07 But you should be able to pick up on to the subtleties of what the parents saying and what the child saying.

    09:12 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.

    09:21 Now reflect to elders.

    09:23 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.

    09:35 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.

    09:48 So a lot of times when you are looking at abused elders a lot of times they were abusers themseles.

    09:55 And you have caregivers telling stories about "how their mom or their dad used to abuse them". Again look for those kinds of patterns.

    10:03 Abused elders are usually vulnerable.

    10:06 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.

    10:17 So be watching for those signs and symptoms as well.

    10:20 Not only physically, emotional, mentally and financially.

    10:25 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.

    10:37 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.

    10:51 We know how tiring 24/7 is taking care of a patient who is totally incapacitated whether physically or mentally.

    10:59 So be watching those people, be asking a lot of questions and be picking up on signs and symptoms.

    11:06 Abusing includes, financial. Again as nurses we don't always know when financial abuse is going on.

    11:13 But you can pick up on signs like may be prescriptions aren't being filled.

    11:17 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.

    11:28 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.

    11:45 May be there has been abused or may be it's leading to abuse.

    11:50 And then risk factors. Again the victims are usually poor health.

    11:55 Elderly people who may be are in wheelchairs.

    11:58 They can't walk on their own.

    12:01 They can't drive on their own. May be they can't see very well.

    12:05 Those patients are all at risk; because, they are physically vulnerable.

    12:09 You also has people that are isolated.

    12:12 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.

    12:21 And may be you can set up like a home care visits.

    12:24 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.

    12:34 Again if things aren't matching up those are the things that as a nurses we should be using our assessment skills.

    12:39 And then mental illness. Again dementia or alzheimer's, those kinds of illnesses where the persons can't tell you what's going on.

    12:48 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.

    13:03 Is that causing stress? Is that causing financial stress? All of those can lead to abuse.

    13:10 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.

    13:19 So what are some of the assessments that you are going to see? Increase agitation is a big one.

    13:24 If you have a patient that is increasingly being agitated or is more agitated when their caregivers are around.

    13:32 Paying attention to that.

    13:34 Looking at those signs and symptoms and documenting that.

    13:37 Anger: Anger for no reason. Again this may be the only way that the elder has to communicate.

    13:44 So be picking up on those signs and don't just automatically think that it's part of their disease process.

    13:50 Fear: Again if they are afraid of being hurt. Afraid of being hit. Afraid of being yelled out.

    13:56 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.

    14:06 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.

    14:15 Again watching that even if the patient, again, can't tell you what's going on.

    14:20 And then depression. Sometimes people think their older people, a lot of them are depressed because of stuck at home.

    14:27 Don't just overlook depression as being as symptoms of just getting old.

    14:32 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.

    14:46 And then weight loss is a sign, if they are not getting nutrients that they should be getting.

    14:51 If they are very dehydrated because they are not getting water.

    14:55 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.

    15:08 Again dehydration that I just mentioned.

    15:11 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.

    15:24 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.

    15:38 Again as a nurse I may not be able to directly effect that. But i know people who can.

    15:45 And if I do my assessment and I document, I can get social services case management involved.

    15:51 So severe skin breakdown is a big one. We know as nurses will watching that all the time in hospitals and nursing homes.

    15:58 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.

    16:08 So if they come into the hospital and they have skin tears and they have pressure ulcers, be asking those questions about. 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.

    16:35 Educate other people that may be aren't directly involved in their care. To be watching for those signs and symptoms of financial abuse.

    16:44 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.

    16:57 You can asking your assessment. But to be aware of those out signs of abuse.

    17:03 So after assessment, as nurses we look at nursing diagnosis.

    17:08 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.

    17:14 Or risk for injury should be at the top.

    17:18 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.

    17:27 Hopefully we can catch some of those things before they happen.

    17:30 Fear should be at the top as well.

    17:33 Patient shouldn't be in fear of the people that are talking care of.

    17:37 But what about powerlessness? If I am elderly and I physically cannot and defend myself.

    17:44 There is a risk of powerlessness.

    17:47 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.

    18:19 And what about altered family processes? That's another big one.

    18:22 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.

    18:31 That we can use to help with that altered family.

    18:35 And then changes in role strain in caregiver role strain. Again as we talked about sometimes parents-children, parents-grandchildren don't ask for the situations that they are put in.

    18:49 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.

    18:59 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.

    19:10 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.

    19:22 That mean may be they are outside playing when they got the injury.

    19:25 But taking note of the hygiene of the child when they come in.

    19:29 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.

    19:39 Again we are looking at the kid decided to do that or do the parents not provide.

    19:45 Failure to thrive: Go back and look at you the pediatric book.

    19:49 We know that there is inorganic and organic failure to thrive.

    19:53 Organic failure to thrive is when there is something physical. But inorganic would be parents not providing the nutrients for the child.

    20:02 We talk a lot about formula and mixing formula and do the parent water down the formula.

    20:07 And what kind effect will that have on the infant? Developmental delays: Again if it is an inorganic reason, be assessing that and picking up on that and documenting that.

    20:20 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.

    20:29 But we need to be finding out what is going on. And we do that by good assessment skills good nursing diagnosis and interventions.

    20:37 And then constant hunger. Again looking at the children if they are always hungry.

    20:42 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.

    21:13 So again being able to ask the right questions to the right people and then documenting.

    21:19 Destruction of valuable: Again that's where the anger come in. Be watching for that.

    21:24 Unattained medical needs: Again, have a child that has asthma if they are not getting their inhalers filled.

    21:31 If they are not getting their steroids filled.

    21:33 Again be asking those questions as to why. Those could be signs of neglect.

    21:40 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.

    21:48 Again a lot of times children will tell you this in the assessment if you get report and you gain redressed.

    21:56 Infants with balds spots. Be looking for those You know do they lay on one spot for long period of time.

    22:02 Be watching for head banging. Be watching for teeth little eroded.

    22:07 Be watching for lack of interest or no bonding with the parents.

    22:12 Again, as a nurse, sometimes these kids are calling out and needing.

    22:17 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.

    22:25 So make sure you use good nursing assessment skills, diagnosis skills and know who you need to report to.

    22:32 Now talk about sexual and emotional abuse.

    22:35 Again what kind of signs, most of these can be apply to the elder as well as the pediatric.

    22:40 And we start with the genital pain.

    22:42 A lot of times kids won't tell you. But they can show you sings and symptoms.

    22:48 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.

    23:09 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.

    23:20 Frequent urinary tract infection, watching for that.

    23:23 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.

    23:45 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.

    24:00 And being able to pick up on that.

    24:02 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.

    24:12 Again being able to pick up and understand that those are all signs and symptoms of sexual abuse.

    24:17 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.

    24:31 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.

    24:42 Domestic abuse: Again remembering that a lot of times this is surrounded by fear.

    24:49 Whether its female or male or whether its the children that are involved.

    24:55 But being able to pick up on signs and symptoms.

    24:58 Being able to do thorough assessment and being able to ask for right question to pick up on domestic abuse.

    25:05 So when looking at nursing - an Identify assessment clues.

    25:10 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.

    25:21 As a nurse i am required to report so knowing when do i report and what are the laws for that.

    25:28 Keep the patient safe.

    25:30 Again that is our ultimate responsibility. We are patient's advocates.

    25:34 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.

    25:44 Be an advocate: Again be looking for questions where you are the patient advocate.

    25:49 and remember that's all the patient has is the nurse.

    25:53 And so answers question to make sure that you are protecting them.

    25:57 And that you are being an advocate.

    25:59 And then know who your resources are and educate families, educate caregivers., educate children on the signs and symptoms of abuse.

    26:09 So post-traumatic response: Again 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.

    26:25 Lot of times people will come in and they have pain in and they can't describe it.

    26:29 And as nurse its our job to make sure that we figure where the pain is and what's causing it.

    26:35 The only way we can do that is our good assessment skills.

    26:39 Ineffective individual coping. Again if they are coping one way or another.

    26:45 Whether its trowing temper tantrum? Whether its denial.

    26:48 Making sure that we are picking up on now.

    26:51 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.

    27:10 You is there identity being taken away from them.

    27:14 Sleep pattern disturbances are huge.

    27:17 May be patients don't know that why they are not getting the sleep that they were getting.

    27:21 But again asking the right questions.

    27:23 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.

    27:34 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.

    27:48 And as a nurse i may not directly be able to affect that.

    27:51 That i can hook them up with social services and case management they can.

    27:56 And then its social isolation/withdrawal.

    27:59 The more somebody is isolated, the risk they are for abuse.

    28:04 And then risk for altered abuse response patterns. Again We don't want the abuse to continue.

    28:11 So what can i do as a nurse? I can assess and i can document, and i can use my skills.

    28:19 to educate and to prevent.

    28:21 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.

    28:29 We are the ones that catch it.

    28:31 We are the ones that bring into light and when our patients can't.

    28:35 So make sure you are looking again at pediatric books and dermatology books.

    28:40 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.

    28:48 And you will be able to answer those question on NCLEX. Good luck.


    About the Lecture

    The lecture Abuse and Neglect by Diana Shenefield, PhD is from the course Psychosocial Integrity. It contains the following chapters:

    • Abuse and Neglect
    • Physical Abuse-Pediatrics
    • Abuse and Neglect - Elders
    • Abuse and Neglect - Assessment of elders
    • Nursing Diagnoses of Elders
    • Sexual and Emotional Abuse
    • Nursing - Identify the assessment clues

    Included Quiz Questions

    1. Removing the patient from any immediate danger
    2. Adhering to the mandatory abuse reporting laws
    3. Notifying the case worker of the family situation
    4. Obtaining treatment for the abusing family member
    1. Stained undergarments
    2. Poor hygiene
    3. Poor eye contact
    4. Bald spots on scalp
    1. Report the case in which the abuse is suspected to the local authorities
    2. Refer the family to the appropriate support groups
    3. Assist the family in identifying resources and support systems
    4. Document the child’s physical assessment findings

    Author of lecture Abuse and Neglect

     Diana Shenefield, PhD

    Diana Shenefield, PhD


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