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Scenario #1: Abuse
• Mr. CO is a 75, year old male. He was admitted to your unit with Pulmonary Fibrosis. As you are walking towards his room to administer medications you hear his son say to him in a nasty tone of voice: “Stop being so stubborn. I need you to give me access to your bank accounts. You’re going to die alone unless you start cooperating”. As you enter he room, the son leaves quickly and you notice the patient has tears in his eyes. You ask “Is everything okay?” Mr. CO shakes his head yes, but remains nonverbal and does not make eye contact. You administer his medications and leave the room.

Directions:
Part 1:
•The original post must be at least 200 – 300 words in length

•What types of elder abuse did you notice in the scenario? (give examples and explain)
•What signs, (in the scenario) if any suggest that the nurse should ask some follow up questions?
•As a nurse in this scenario what is your next action?
•How can older adults protect themselves from ever becoming victims of abuse or mistreatment?

Scenario #2

You are viewing social media at home when you notice one of your coworker’s post on Facebook. The post is complaining about an elderly patient on your unit at work. The post reveals that the patient has Alzheimer’s disease and is “crazy” and your coworker states “I can’t wait until she is transferred out of here and back to Comfort Care Homes. After this shift, you will find me at the bar, line them up, I will need it.” Additionally, the coworker’s full name, occupation and employer are listed on their “about me” page.

Respond with atleast 100 words not more than 150 words

1. What would you do regarding this posting? Explain clearly what you would do and why.

Gerontologic nursing

Chapter 3: Legal and Ethical Issues

Professional Standards

Health care providers have a general obligation to live up to accepted or customary standards of care

Federal and state statutes require nursing facilities to have written health care and safety policies

Sources of Law

Statutes are laws created by legislation and are enacted at the federal and state level

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

In some states failure by clinicians to report suspected incidents of mistreatment is a misdemeanor punishable by fine or penalty

Sources of Law

HIPAA

Health Insurance Portability and Accountability Act

1996

Increase a person’s ability to get health care coverage when the person begins a new job

Help maintain continuous health coverage when a change of job occurs

Limits the use of preexisting conditions

Sources of Law

Every state in America has mechanisms for reporting elder mistreatment

Adult Protective Services (APS) programs exist in each state

Standards of care for nursing homes are based on policy stipulated in the Nursing Home Reform Act of 1987 (Omnibus Budget Reconciliation Act, 1987)

Many states currently have mandatory reporting laws for elder mistreatment in which nurses & health care practitioners are required by law to report suspected cases

Elder Abuse

Categories of Elder Mistreatment

3 basic categories of elder mistreatment

Domestic treatment – older persons home – by child, spouse, In-law)

Institutional mistreatment – contractual arrangement & suffer abuse – LTC facilities, assisted living, rehabilitation or hospital

Self neglect or self abuse – are mentally competent enough to understand the consequences of their own decisions – that threaten their own safety

Institutional Mistreatment

The types of mistreatment that occur in nursing homes likely mirror those in domestic settings

Physical abuse

Sexual abuse

Neglect

Financial abuse

Psychological abuse

Researchers have also speculated that shortages of staff, inadequate training of staff & staff burnout may be precipitating factors in mistreatment of nursing home residents

Institutional Mistreatment

Delay in reporting incidents

Residents afraid of retribution

Family members may fear having to find a new nursing home

Staff may fear losing their jobs

Facing recrimination by other staff members

Want to avoid adverse publicity

Assessment

Ideally the older adult and any suspected abuser should be interviewed separately

Maintaining a nonjudgmental approach will enable the nurse to obtain more accurate data

The physical symptoms of elder mistreatment are often difficult for clinicians to discern because older adults may suffer from chronic and acute illness that mask or mimic the presence of mistreatment

Assessment

Their self reporting may be questioned for accuracy or they may be unable to express the mistreatment situation due to

Amnesia

Aphasia – total or partial loss of ability to speak or understand language

Agnosia – inability to recognize common people and things

Apraxia – inability to perform simple task

It is often difficult to determine whether the older adult’s worsening physical condition is a result of the natural progression of illness or mistreatment

Because some frail older individuals are prone to underlying conditions that give rise to trauma, such as instability of poor gait and poor vision resulting in falls, it may be difficult to differentiate accidental from willful injuries

Types of Elder Mistreatment

Physical abuse

Psychological / emotional abuse

Sexual abuse

Financial exploitation

Caregiver neglect

Self neglect

Abandonment

Institutional mistreatment

Physical Abuse

Intentional infliction of physical injury or pain

Hitting

Shaking

Pushing

Improper use of physical

restraints

Signs & symptoms

Bruises

Black eye

Bone fractures

Injuries in various stages of healing

Reports of being hit or mistreated

Psychological / Emotional Abuse

Infliction of anguish, pain or distress

Yelling / verbal attacks

Swearing

Name calling

Belittling

Signs & symptoms

Emotional upset

Agitation

Extreme with drawl

Sexual Abuse

Any form of nonconsensual sexual intimacy

Rape

Molestation

Sexual harassment

Signs & symptoms

Genital bruising

Unexplained sexually transmitted disease

Financial Exploitation

Taking advantage of an older person for monetary or personal benefit

Unexplained monetary expenditures

Lack of money for personal necessities

Theft

Fraud

Signs & symptoms

Unexplained inability to pay bills

Inability to purchase necessity items such as food

Caregiver Neglect

Intentional (active) or unintentional (passive) failure to meet needs necessary for elder’s physical & mental well being

Failure to provide adequate food, clothing, shelter, medical care, hygiene or social stimulation

Signs & symptoms

Dehydration

Malnutrition

Unattended or untreated health problems

Listlessness

Decubitus ulcers

Urine burns

History of being left alone

Self Neglect

Personal disregard or inability to perform self care

Poor hygiene

Unkempt home environment

Signs & symptoms

Malnutrition

Fungal skin & nail infection

Insect & rodent infestation in the home

Abandonment

Desertion or willful forsaking of an elder

Dropping off an elder adult in the emergency department

Desertion

Signs & symptoms

An older adult left inappropriately alone

Institutional Mistreatment

When older adult has a contractual arrangement & suffers abuse or neglect

May be any combination of the afore mentioned

Signs & symptoms

Can be any of the signs & symptoms of the other examples of abuse

Characteristics of Older Adults at Risk

Difficult to obtain

Several characteristics are more common among victims

Sex

Age

Race

Low socioeconomic status

Low educational levels

Impaired functional or cognitive status

History of domestic violence

Stressful events

Depression

Interventions

Health care workers must be aware of local elder mistreatment reporting laws in their state

Many states have mandatory reporting laws & health care professionals must report suspected cases

In cases were abuse is suspected an older adult may benefit from a hospital admission to allow the healthcare team to carefully assess & formulate a plan of care

Documentation

Excellent documentation is extremely important in elder mistreatment cases

Objective documentation

Unbiased manner

Physical indicators that are clearly documented will assist in discussing & planning goals

Photo documentation is especially warranted in cases where there is evidence of physical or sexual abuse

Residents Bill of Rights

Most facilities have developed a contract for new residents to sign at the time of admission

Called admission agreement

This agreement sets forth the rights, obligations and expectations of each party

It is a way to inform residents of a facility’s rules, regulations and philosophy of care

See Box 3 – 1 on page 37 “Residents Bill of Rights”

Unnecessary Drug Use & Chemical & Physical Restraints

The OBRA requires that nursing facility residents be free of unnecessary drugs of all types, chemical restraints and physical restraints

Chemical restraints

Drugs that are used to limit or inhibit specific behaviors or movements

Physical restraints

Are appliances that inhibit free physical movement

Limb, vest, waist

Wheelchairs, geriatric chairs & side rails may also be restraints

Unnecessary Drug Use & Chemical & Physical Restraints

The nurse must carefully document the behavior or condition that led to the order for a restraint

Residents receiving antipsychotic drugs must have an indication for the use of the drug

Reasons must be documented in the physician’s order and chart / care plan

Advanced Medical Directives

Documents that permit people to set forth in writing their wishes and preferences regarding health care

Used to indicate their decisions if the time should come when they are unable to speak for themselves

An advance directive is not operative until the patient is no longer capable of decision making

Living Wills

Are intended to provide written expressions of a patient’s wishes regarding the use of medical treatments in the event of a terminal illness or condition

The patient’s wishes regarding the withholding or with drawl of life support

Living Will

Not effective until:

The attending physician has the document and the patient has been determined to be incompetent

The physician has determined the patient has a terminal condition or a condition such that any therapy provided would only prolong dying

The physician has written the appropriate orders in the medical record

Durable or General Power of Attorney

May designate someone else to make health care decisions at a time in the future when they may be rendered incompetent

The role of the designated surrogate in this situation is to make the decisions that most closely align with the patient’s wishes, desires and values

Conflicts

Families may disagree with the directives of a family member

Often family members express the desire to have more care than is requested by a patient

The law upholds the expressed desires of a patient over those of the family

But families may try to exert influence to bring about a decision that is sometimes contrary to the patient’s expressed wishes

POLST

Physician Orders for Life Sustaining Treatment

Process of communicating health care wishes during a medical crisis or decline in health

Include:

Cardiopulmonary resuscitation (CPR)

Medical interventions

Artificially administered nutrition

See Table 3.1 on page 42

See Figure 3.2 on page 42

PSDA

Patient Self-Determination Act

Came into effect 12/1/1991

To ensure that patients are given information about the extent to which their rights are protected under state law

Requires hospitals, nursing facilities and other health care providers who receive federal funds such as Medicare or Medicaid to give patients written information explaining their legal options for refusing or accepting treatment should they become incapacitated

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