Question

I. History of Present Problem:

John Peterson is an 82-year old male who is brought to the emergency department (ED) by his son because of concerns of caregiver neglect. John lives in his apartment and requires help with ADLs during the day. When the son visited his dad, he found him soaked in urine, surrounded by spoiled food, with dried vomit on his clothing. The trash cans outside the home were overflowing, and inside, there was debris and old food left on the bedroom and kitchen floors. John is complaining of pain in his feet, which he attributes to his diabetes. The son reports that his current caregiver is a family friend who has a history of drug addiction and may have relapsed.

The patient is alert and oriented and admits to feeling sickly.  He does not remember when he last had a glass of water. There is a distinct smell of feces and urine. Upon closer assessment, there are dried feces in his perirectal area and redness in his groin folds. There is also evidence of skin tears/bleeding on the left lateral thigh that appeared to be of a friction/shear type mechanism. Mr.  Peterson states that he has not had a bath in three weeks. He also reports being unable to get up from the chair by his bed without assistance for the last three days because of increasing weakness and fatigue.  

Personal/Social History:

Mr. Peterson’s son, Frank, reports that the patient was relatively healthy and self-sufficient up until the age of about 77. His first wife, Frank’s mother, died 20 years ago. He remarried two years after his first wife died. Frank and his father’s second wife, Janet, did not get along well, which resulted in a more distant relationship between father and son.  Frank lives about four hours away, is an only child, and visits 2-3 times a year.  

When Janet died a year ago, it first became apparent that John needed help with day to day functioning.  John was resistive to leaving his home or having “strangers” come into his house but finally agreed to let a family friend help out. During a previous visit, Frank noticed that his father had a frailer appearance and was more forgetful.   It has been about three months since his last visit. Frank reports that his father does not have many visitors or close friends that are still alive.

What data from the histories is important & RELEVANT; therefore, it has clinical significance to the nurse?

(Reduction of Risk Potential)

RELEVANT Data from Present Problem:	Clinical Significance:
RELEVANT Data from Social History:	Clinical Significance:

Resolving the Dilemma

1. Interpreting RELEVANT clinical data, what is the essence of this clinical dilemma and the current priority?(NCLEX: Management of Care)

2. Identify the differences between patient abuse and neglect. What are the most common findings that are clinical RED FLAGS for the nurse?

3. What is the nurse's role in reporting suspected abuse, neglect, or exploitation?

4.What additional information is needed by the nurse to clarify the dilemma? (NCLEX: Management of Care)

5. What additional members of the healthcare team can be used in this situation? Why? (Management of Care)

6. What does the nurse need to know to provide culturally competent care? (NCLEX: Management of Care)

7. What is the nursing PRIORITY? (NCLEX: Management of Care)

8. What are the PRIORITY nursing interventions? (NCLEX: Management of Care)

PRIORITY Nursing Interventions:	Rationale:	Expected Outcome:

9. What principles of therapeutic communication can be utilized to develop trust and encourage dialogue

between the nurse, patient, and/or family? (Management of Care) and (Psychosocial Integrity)

10. What is the expected response of the patient/family/caregiver (Management of Care)?

11. What is the patient and/or family likely experiencing/feeling right now in this situation?

(Psychosocial Integrity/Basic Care and Comfort)

12. What can I do to engage myself with this patient’s experience, and show that the individual matters to me as a person? (Psychosocial Integrity/Basic Care and Comfort)

Reflect on Your Thinking to Develop Clinical Judgment

To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions:

What did you do well in this case study?	What knowledge gaps did you identify?
What did you learn?	How will you apply learning caring for future patients?

Answer 1

RELEVANT DATA FROM PRESENT PROBLEM( CLINICAL SIGNIFICANCE):

• DIABETES
• DEHYDRATION.
• PRESSURE ULCERS.
• DEMENTIA
• POOR NUTRITIONAL STATUS.

EXPLANATION:

• DIABETES: PAIN IN HIS FEET DUE TO DIABETES.
• DEHYDRATION: UNABLE TO GET UP FROM CHAIR DUE TO FATIGUE AND WEEKNESS.
• PRESSURE ULCERS:EVIDENCE OF SKIN TEARS OR BLEEDING ON THE LEFT LATERAL THIGH
• DEMENTIA: HE DOES NOT REMEMBER WHEN HE LAST HAD A GLASS OF WATER.
• NUTRITIONAL STATUS: FATIGUE AND WEEKNESS.

RELEVANT DATA FROM SOCIAL HISTORY: CLINICAL SIGNIFICANCE:

• DEPRESSION DUE TO LONELINESS.
• LACK OF SOCIALIZATION.
• LOSS OF MEMORY (DEMENTIA)

ESSENCE OF THE CLINICAL DILEMMA AND THE CURRENT PRIORITY:

• IMMEDIATE REQUIREMENT OF DAILY CARE (ADL).
• MANAGEMENT OF DIABETES TO ENSURE REGULAR MEDICATION.
• TREATMENT OF PRESSURE ULCERS.
• IMPROVE NUTRITIONAL STATUS.

DIFFERENCES BETWEEN PATIENT ABUSE AND NEGLECT:

PATIENT ABUSE	PATIENT NEGLECT
INTENTIONAL HURTING OF AN INDIVIDUAL EITHER PHYSICALLY OR MENTALLY .	LACK OF CARE RESULTS IN POOR REQUIRED ACTION
SEXUAL ABUSING , HARMING THE PATIENT EMOTIONALLY	FAILURE TO PROVIDE PROPER NUTRITION, MEDICINES

MOST COMMON FINDINGS THAT ARE CLINICAL RED FLAGS FOR THE NURSE:

• DIABETES
• DEHYDRATION
• PRESSURE SORES.
• DEMENTIA.

ADDITIONAL INFORMATION NEEDED BY THE NURSE TO CLARIFY DILEMMA:

• ONSET AND DURATION OF DIABETES.
• CURRENT MEDICATIONS.
• SOCIAL HISTORY OF ALCOHOL OR SMOKING OR DRUGS.
• PREVIOUS HISTORY OF INVESTIGATIONS AND DIAGNOSIS.

ADDITIONAL MEMBERS OF THE HEALTHCARE TO BE USED IN THIS SITUATION:

• FAMILY PHYSICIAN: TO REGULATE AND MANAGE THE DIABETES AND PRESSURE ULCERS.
• PSYCHIATRIST/PSYCHOLOGIST: TO ASSESS AND TREAT DEMENTIA.
• NUTRITIONIST: TO PROVIDE HEALTHY BALANCED DIET TO AVOID DEHYDRATION, FATIGUE AND WEEKNESS.
• PHYSIOTHERAPIST: DUE TO RESTRICTION OF MOVEMENTS AND UNABLE TO GET UP FROM CHAIR.