saladinja.weebly.com · web viewin this paper, this author describes an elderly woman who presented...

ANALYSIS OF GERIATRIC

1

Analysis of Geriatric Care Needs

Julie A. Saladin

Ferris State University

ANALYSIS OF GERIATRIC 2

Abstract

In this paper, this author describes an elderly woman who presented to the hospital with serious

facial injuries under false pretenses. The nursing staff’s assessment revealed that the patient was

actually abused by her caregiver, who was also her husband. After the husband removed the

patient from the hospital against medical advice (AMA), the nurse completed an Elder

Assessment Instrument (EAI) indicating the patient had indicators for abuse and reported the

abuse to Adult Protective Services (APS). APS investigated the allegation within 24 hours and

found that the caregiver had harmed his wife due to caregiver burnout. The patient was

readmitted to the hospital and the nurse completed her assessment. Three main diagnoses were

identified with a plan of care developed between the patient and the nurse. Implementation of

interventions is discussed. Evidence-based clinical guidelines were used to support the nursing

interventions. A plan to evaluate the interventions is identified with a focus on policy changes

needed to decrease elder abuse.


Analysis of Geriatric Care Needs

This paper describes the abuse of an elderly woman who presented to the hospital with

facial fractures and injuries. The husband, who is also the caregiver, told staff that the patient

had fallen and was intent on not allowing the patient to speak for herself in fear that she might

tell the staff what truly happened. The nurse suspected abuse and had an opportunity to get the

patient alone when her husband went for coffee. The patient confirmed that the husband abused

her and when the husband returned to find the nurse speaking with his wife, he had her

discharged against medical advice (AMA). The nurse was able to complete an EAI tool

(Appendix) to confirm the patient had been abused and reported the suspected abuse to Adult

Protective Services (APS). The patient was eventually returned to the hospital and the nurse

worked with the patient to develop a plan of care that would increase patient safety and overall

well-being. Evidence-based nursing interventions were put into place after the nurse completed a

thorough assessment of the patient.

Assessment

According to Touhy & Jett’s case study, the patient is an 87 year old female recently

admitted to the medical surgical floor of a local hospital with a fracture of the right orbit and a

ruptured eye globe. She lives at home with her husband who presents as though he is concerned

about her well-being. The patient is alert and oriented but brittle and withdrawn. Her husband

answers all questions that all of the health care professionals ask without allowing the patient the

opportunity to interject any responses. This reaction by the husband causes the patient to

become further withdrawn. The husband stays by the patient’s side for many hours, but leaves

briefly to get a cup of coffee (2012, p. 407).


The study goes on to reveal that the nurse quickly asks the patient what happened while

her husband is out of the room, and the patient started to cry stating that her husband hit her. The

nurse offered her protective services which she declined, because she had “nowhere else to go”.

The husband returned to see that the nurse was speaking with his wife and packed her up and left

the hospital against medical advice (Touhy & Jett, 2012, p. 407).

The nurse was able to take the information that she had obtained through observation,

and the short conversation with the patient, and applied the information to the Elder Assessment

Instrument (EAI) (Appendix)(The Hartford Institute for Geriatric Nursing, 2012) to “recognize

indicators of mistreatment of older adults” (Lippincott’s Nursing Center.com, 2014). In the

General Assessment portion of the EAI assessment, the nurse was only able to identify that the

patient had facial bruising that accompanied the facial fracturing. There was no mention of the

patient’s clothing or hygiene being disheveled in any way, and the patient had left the hospital

prior to testing labs for determination of nutritional status. The possible abuse indicators

identified on the EAI assessment were the fractures and the statement from the elder regarding

her husband hitting her. There were no indicators of neglect, exploitation, or abandonment

divulged on the assessment.

After assessing the encounter that the nurse had with this patient, the nurse determined

that the patient was being abused by her husband, who was also her primary caregiver. The

patient was not able to verbalize her feelings because she was fearful of her husband who was

the perpetrator. Although fearful of her husband, he was also her caregiver and this put a strain

on their relationship. The patient stated she had nowhere else to go. She felt powerless related to

a lifestyle of helplessness (Mosby’s Guide to Nursing Diagnosis, 2014). She did not want


protection from the abuse because she did not wish to be removed from her home, and although

her husband was abusive, he was also her family.

Besides the psychological aspects of this elder’s current condition, the patient is an 87

year old female whose body has gone through many biological changes which are explained

throughout the biological theories of aging. The biological theories attempt to answer how aging

is “manifested on the molecular level in the cells, tissues, and body systems; how does the body-

mind interaction affect aging; what biochemical processes impact aging; and how do one’s

chromosomes impact the overall aging process (Mauk, 2014, p. 75). Although very little is

known about this patient’s medical history, these theories provide a basic understanding of the

aging process which accounts for the patients general frailty and elderly state.

The free radical theory explains that when the body uses oxygen it produces free radicals

which damage membranes, proteins, and nucleic acids causing cellular injury and aging (Mauk,

2014, pp. 76-83). This patient did not present with any disease process making the nurse believe

that this is the theory that can be applied to the aging process for this woman. The more likely

theory that fits this patient’s ideology is the wear and tear theory. This theory simply proclaims

that a person’s cells “wear out and cannot function with aging” (Mauk, 2014, pp. 78-83). This

patient did not present with any known disease processes. She presented with fractures of the

face, most likely incurred from spousal abuse. She was simply a woman who had gone through

the normal aging process which many would refer to as normal wear and tear.

The patient did not exhibit signs of aging caused from the immunity theory as she did not

present with an autoimmune response or diagnosis that would indicate such (Touhy & Jett, 2012,

p. 35). There is no viable evidence showing that the cross-linkage theory or that the error theory

was the perpetrator in her aging process, as there was no information gathered, or testing done, to


make these types of determinations (Touhy & Jett, 2012, pp. 35-36). The patient presented as a

normal elderly woman who had been victim of spousal abuse; which left her feeling as though

she could not talk to anyone but the person who was abusing her, and that she was powerless

against the abuse because she had nowhere else to go.

Diagnosis

Based on the assessment findings, there are three NANDA approved nursing diagnosis

the nurse felt appropriate to use in caring for this patient. The first is “Impaired verbal

communication related to psychological barriers of fear” (Mosby’s Guide, 2014). The second is

“Compromised family coping related to abusive patterns” (Mosby’s Guide, 2014). The third

diagnosis is “Powerlessness related to lifestyle of helplessness” (Mosby’s Guide, 2014). It was

clear to the nurse that the patient was abused and that the patient was too fearful of verbalizing

the abuse. The patient felt as though she had no way out and that the relationship she had with

her husband was the only relationship that she could depend on. Following through with a plan

of care for this patient would be difficult because the husband removed the patient from the

hospital against medical advice. This event made it even more crucial that the health care

providers follow through with their assessment findings.

Planning

Typically the nurse is able to develop a trusting relationship with the patient in order to

begin the planning process for a plan of care. In a case where abuse or neglect is present, this

relationship may be difficult to achieve. “Abuse and neglect is not uncommon, and careful

assessment and the development of a trusting professional relationship may be helpful in helping

abused persons share their experience” (Black, 2014, p. 246). Because the nurse was not able to

develop this relationship, the first priority of the nurse is to report the suspected abuse to the


Department of Human Services (DHS), Adult Protective Services (Department of Human

Services, 2014). In many hospital settings, the results of the EAI might be discussed with an

interdisciplinary team and the social worker might report the abuse.

For purposes of this paper, and the plan of care, we will say that the suspected abuse was

reported, Adult Protective Services investigated the claim, and the patient was re-admitted to the

hospital. The husband, who is the primary caregiver, agreed to receiving help and the patient

agreed to receive help as long as she was able to go back to her own home. The same nurse who

spoke with the patient during the first admission admitted the patient again and discussed a plan

of care with the patient. The nurse found that the husband may be exhibiting signs of caregiver

burnout. “Caregiver stress and burnout can trigger abusive behavior” (Stark, 2012). So the plan

would include providing the husband with assistance as well. The patient was alert and oriented

but required quite a bit of assistance with her daily needs due to her frailty. The husband was

providing this care and did all of the cooking and cleaning because the patient “just couldn’t get

around like she used to”. Community resources were discussed and would be utilized to assist

the patient and the husband in their home.

The nurse explained to the patient the consequences of allowing the physical abuse to

continue. She explained that older people have bones that are more brittle and take longer to

heal. “Even a relatively minor injury can cause serious and permanent damage” (World Health

Organization, 2002). The patient developed a trusting relationship with the nurse and the patient

became comfortable in speaking about the abuse. She discussed her relationship with her

husband and stated that she still loved him very much. The patient’s feelings of powerlessness

were still present because she felt she couldn’t change anything due to her weakened state and

felt that she “was at the mercy of those who cared for her” most of the time. The patient


verbalized an understanding, and agreed with; creating a plan of care that would assure her safety

and well-being.

Implementation

The nurse will educate the patient in the importance of self-reporting and provide

assurance that “Nursing home placement is not the usual intervention for victims of abuse”

(Ziminski Pickering and Rempusheski, 2014, p. 124). There are safe houses and other short term

living arrangements that can be made for a person in danger of abuse. The nurse will explain

that these safe houses are available at no cost to the patient. This information may alleviate some

of the hesitation in self-reporting.

The patient will agree to self-report further instances of physical abuse or fear that abuse

may occur. She will be able to identify two available resources that she can utilize if she needs

help. The patient will verbalize a way to access the resources.

The nurse will provide educational materials on abuse and explain that there is never an

excuse or reason for abuse (Ziminski Pickering et al., 2014). Providing printed materials that the

patient can read over will help reiterate what the nurse has taught the patient and provide the

patient with resources of her own for further review (U.S. Department of Human & Health

Services, 2013). Many of these resources are free of charge or there is a website that helps the

patient to figure out what costs might be covered (U.S. Department of Human & Health, 2013).

The patient will read over the information with the nurse and ask questions if she has any

concerns. She will verbalize that the abuse was not her fault. She will be able to identify the

difference between elder abuse and domestic abuse.

The nurse will promote verbal communication, but will be sensitive to other types of

nonverbal communication cues should the patient not be able to verbalize a concern. The nurse


will actively listen and use open-ended questions to elicit open communication (Black, 2014, pp.

179-181). The nurse will use silence when appropriate because “Being with patients (presence) is

just as valuable as doing for them and conveys respect for the patient’s feelings under

troublesome circumstances” (Black, 2014, p. 182).

The patient will show that she is comfortable with the nurse by openly discussing her

concerns. She will engage in conversation and not simply respond with yes and no answers.

The patient will be comfortable sitting in silence with the nurse.

The nurse will be physically and emotionally available for the patient (Mosby’s Guide,

2014). She will encourage the patient to engage in spiritual rituals with her family, such as

prayer (Mosby’s Guide, 2014). The nurse will refer the patient to support groups within the

community and resources where volunteers come to visit with her in her own home. The

Eldercare Directory provides information on available resources to assist the elder once back in

the community (Eldercare Directory, 2014). The nurse will educate the caregiver on coping

interventions and available resources (Mosby’s Guide, 2014).

The patient will contact a support group prior to leaving the hospital. She will set up an

appointment for someone to evaluate her husband’s needs as well. The caregiver will verbalize

appreciation for the assistance of available resources.

The nurse will assist the patient in trusting herself and others (Mosby’s Guide, 2014).

She will promote and support the patient’s belief of power and control over her own lifestyle

(Mosby’s Guide, 2014). The nurse will collaborate with the patient and identify resources to help

initiate a plan so that the patient feels empowered (Mosby’s Guide, 2014).

The patient will express a wiliness to trust other people from support groups to come into

her home and provide assistance. She will voice her opinion with her spouse and make decisions


regarding her healthcare needs. The patient will speak for herself. She will assist in making

decisions about her plan of care for achieving overall wellness.

Evaluation

The patient will express a desire for social interaction and will demonstrate the ability to

verbally communicate concerns and needs within two months (Mosby’s Guide, 2014). She will

report an increase in mood and psychological well-being within one month (Mosby’s Guide,

2014). The patient will state that she is managing stress at home, which will be indicated in her

behavior, within two months (Mosby’s Guide, 2014). She will show that she has sought out the

support of social groups within the community to assist with coping within one month (Mosby’s

Guide, 2014). The patient will make decisions regarding her health care within one month. She

will elicit the help of others prior to leaving the hospital (Mosby’s Guide, 2014). The patient will

voice that she is not being abused and will not present with any new indicators of abuse

beginning while in the hospital. These indicators could include bruising, scratches, fractures,

aggressive behaviors, withdrawn personality, unusual behavior, and signs of fear (Touhy and

Jett, 2012, pp. 401-405).

Policy

Elder abuse is a rapidly growing problem. “It is predicted that by the year 2025, the

global population of people aged 60 years and older will more than double, from 542 million in

1995 to about 1.2 billion” (WHO, 2014). Locally, it is prevalent in our communities and the

homes in which our elderly population live. The extent of abuse happening in our communities

is not known because of elders like this patient who won’t report abuse because they are too

fearful of losing their home, and all that is familiar to them.


Public and professional awareness are instrumental in preventing abuse in our

communities. Educating caregivers on stress management and dementia care are vital to

preventing caregiver burnout (WHO, 2014). According to the WHO, interventions to reduce

elder maltreatment should include “screening potential victims, mandatory reporting of

maltreatment to authorities, adult protective services, home visitation by police and social

workers, self-help groups, safe-houses and emergency shelters, and caregivers support

interventions” (2014).

Conclusion

The 87 year old patient depicted in this paper is one of the lucky ones because the abuse

was caught prior to serious permanent damage, or death. The patient’s caregiver was rough with

his wife due to caregiver burnout. The fact that he brought her to the hospital for care, even

under false pretenses, shows that he ultimately cared for her well-being. The nurse had the

skillset to recognize the signs and symptoms of elder abuse, and the foresight to know she

needed to speak to the patient while she was alone to get the true story. Even though this upset

the husband, causing him to remove his wife from the hospital, the nurse knew she needed to

complete the EAI tool and report the possible abuse. Adult Protective Services was notified and

investigated the allegation. The patient was returned to the hospital where she could get the

appropriate treatment and work with the nurse to develop a plan of care needed to increase her

overall safety and well-being.


References

Black, B. P. (2014). Professional nursing: Concepts & challenges (7th ed.). St. Louis, MO:

Elsevier Saunders.

Department of Human Services. (2014). Adult protective services. Retrieved from

http://www.michigan.gov/dhs/0,4562,7-124-7119_50647---,00.html

Eldercare Directory, Essential resources for senior citizens and their caregivers. (2014). State

Resources. Retrieved from http://www.eldercaredirectory.org/state-resources.htm

Ladwig, G.B., & Ackley, B.L. (2014). Mosby’s guide to nursing diagnosis (4th ed.). Maryland

Heights, Missouri: Elsevier Saunders.

Lippincott’s Nursing Center.com. (2014). How to try this: Screening for mistreatment of older

adults. Retrieved from http://nursing.ceconnection.com/nu/public/modules/1670

Mauk, K. L. (2014). Gerontological nursing: competencies for care (3rd ed.). Burlington, MA:

Jones and Bartlett Publishers.

The Hartford Institute of Geriatric Nursing, New York University, College of Nursing. (2012).

Elder Mistreatment Assessment. try this: Best practices in nursing care to older adults,

15. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

Stark, S. (2012). Elder abuse: Screening, intervention, and prevention. Nursing2014, 42(10), 24-

29. Retrieved from http://www.nursingcenter.com/lnc/CEArticle?an=00152193-

201210000-00010&Journal_ID=54016&Issue_ID=1433745

Touhy, T. A., & Jett, K. F. (2012). Ebersole & Hess' toward healthy aging: Human needs &

nursing response (8th ed.). St. Louis, Mo.: Elsevier/Mosby.

U.S. Department of Health and Human Services, Administration for Community Living (ACL).

(2013). Help & Resources. Retrieved from http://www.acl.gov/Get_Help/Index.aspx


U.S. Department of Health and Human Services, Administration on Aging (AoA). (2013). Costs

& how to pay. Retrieved from http://longtermcare.gov/costs-how-to-pay/

World Health Organziation [WHO]. (2002). Abuse of the elderly. Retrieved from

http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/

elderabusefacts.pdf

Ziminiski Pickering, C. E., & Rempusheski, V. F. (2014). Examining barriers to self-reporting of

elder physical abuse in community-dwelling older adults. Geriatric Nursing, 35(2), 120-

125. doi: 10.1016/j.gerinurse.2013.11.002


Appendix

general assessment series

Best Practices in Nursing Care to Older Adults

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

Issue Number 15, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing

Elder Mistreatment AssessmentBy: Terry Fulmer, PhD, APRN, GNP, FAAN, Bouve College of Health Sciences, Northeastern University

WHY: Elder abuse and neglect is a serious and prevalent problem that is estimated to affect 700,000 to 1.2 million older adults annually in this country. Only one in ten cases of elder abuse and neglect are reported and there is a serious underreporting by clinical professionals, likely due to the lack of appropriate screening instruments. Abuse, neglect, exploitation, and abandonment are actions that can result in elder mistreatment (EM).

BEST TOOLS: The Elder Assessment Instrument (EAI), a 41-item assessment instrument, has been in the literature since 1984 (Fulmer, Street, & Carr, 1984; Fulmer, & Wetle, 1986; Fulmer, Paveza, Abraham, & Fairchild, 2000). This instrument is comprised of seven sections that reviews signs, symptoms and subjective complaints of elder abuse, neglect, exploitation, and abandonment. There is no “score”. A patient should be referred to social services if the following exists:1) if there is any evidence of mistreatment without sufficient clinical explanation2) whenever there is a subjective complaint by the elder of EM3) whenever the clinician believes there is high risk or probable abuse, neglect, exploitation, abandonment

TARGET POPULATION: The EAI is appropriate in all clinical settings and is completed by clinicians that are responsible for screening for elder mistreatment.

VALIDITY AND RELIABILITY: The EAI has been used since the early 1980’s. The internal consistency reliability


(Cronbach’s alpha)is reported at 0.84 in a sample of 501 older adults who presented in an emergency department setting. Test/retest reliability is reported at 0.83 (P<.0001). The instrument is reported to be highly sensitive and less specific.

STRENGTHS AND LIMITATIONS: The major strengths of the EAI are its rapid assessment capacity (the instrument takes approximately 12-15 minutes) and the way that it sensitizes the clinician to screening for elder mistreatment. Limitations include: no scoring system and weak specificity.

MORE ON THE TOPIC:

Best practice information on care of older adults: www .ConsultGeriRN.org .Aravanis, S.C., Adelman, R.D., Breckman, R., Fulmer, T., Holder, E., Lachs, M. S., O’Brien, J.G., & Sanders, A.B. (1993).

Diagnostic and treatment guidelines on elder abuse and neglect. Archives of Family Medicine, 2(4), 371-88. Fulmer, T. (2008). Screening for mistreatment of older adults. AJN, 108(12), 52-59.Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(1), 8-9. Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(6), 4-5.Fulmer, T., & Cahill, V.M. (1984). Assessing elder abuse: A study. Journal of Gerontological Nursing, 10(12), 16-20.Fulmer, T., Guadagno, L., Bitondo-Dyer, C., & Connolly, M. T. (2004). Progress in elder abuse screening and assessment instruments.

JAGS, 52(2), 297-304.Fulmer, T., Paveza, G., Abraham, I., & Fairchild, S. (2000). Elder neglect assessment in the emergency department.

Journal of Emergency Nursing, 26(5), 436-443.Fulmer, T., Street, S., & Carr, K. (1984). Abuse of the elderly: Screening and detection. Journal of Emergency Nursing, 10(3), 131-140. Fulmer, T., & Wetle, T. (1986). Elder abuse screening and intervention. Nurse Practitioner, 11(5), 33-8.Neale, A., Hwalek, M., Scott, R., Sengstock, M., & Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test.

Journal of Applied Gerontology, 10(4), 406-418.

general assessment series

A series provided by The H

artford Institute for Geriatric N

ursing, N

ew York University, C

ollege of Nursing

EMAIL hartford.ign@

nyu.edu HARTFORD INSTITUTE WEBSITE w

ww

.hartfordign.orgBest Practices in Nursing Care to O

lder Adults


Elder Assessment Instrument (EAI)

Adapted from: Fulmer, T., & Cahill, V.M. (1984). Assessing elder abuse: A study. Journal of Gerontological Nursing, 10(12), 16-20; Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(6), 4-5; Reprinted from Journal of Emergency Nursing, 10(3). Fulmer, T., Street, S., & Carr, K. Abuse of

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