Question

SECOND TOPİC: An Abuse Case

Mrs. Angel is a 89-year-old woman. She has a retirement pension. Her husband died a year ago. She stays at her daughter's house. Her daughter works in a factory. Her daughter's husband, Ahmet, is an unemployed, alcoholic man with sexual problems. They have a four-year-old child.

Mrs Angel is brought to the emergency unit by her daughter and Ahmet with severe abdominal pain. On physical examination, she was found to have vaginal bleeding, as well as bruises on her legs and arms. In the radiological examination, an old fracture is found on her arm. Mrs Angel does not want to answer the questions asked to her and remains silent. And whenever a question is asked, she looks at her daughter's face. The doctor and nurse performing the physical examination are suspicious from this situaton:

1.What hints do you think caused the Emergency doctor and nurse to be suspicious? What kind of abuse did they suspect? Tell the story clearly by interpreting it.

2. Explain step by step what the doctor and nurse should do to clarify the case. (This question will be answered on at least 1 page)

3. What evidence can they collect as evidence of crime?

4. Examine international legal and ethical regulations for elderly abuse and compare them with legal and ethical regulations in your country. (This question will be answered on at least 1 pages)

5. Prepare a campaign that will raise awareness of elder abuse in the community. Write the content of this campaign and find a AWARENESS SLOGAN.

Answer 1

1.In the above scenario, the patient exhibit signs and symptoms such as severe abdominal pain and vaginal bleeding,bruises on her legs and arms. An old fracure found in radiological examinations, her histoey reveals dughter's husband is an unemployed,alcoholic man with sexual problems.more over her facial expressions towards questions reveals that there is a posibility of sexual abuse.

2.
Elder sexual abuse includes any sexual contact with an elder who, because of mental illness or dementia, cannot communicate their disapproval of the behavior against them or cannot communicate consent for the activity. If your loved one has suffered from sexual abuse in a nursing facility or nursing home, then you should consider.

Individuals who have suffered sexual violence, irrespective of the point at which they present within the health sector, should be offered a full medical-forensic examination, the main components of which are as follows:

— an initial assessment, including obtaining informed consent

— a medical history, including an account of the events described as sexual violence

— a “top-to-toe” physical examination

— a detailed genito-anal examination

— recording and classifying injuries

— collection of indicated medical specimens for diagnostic purposes

— collection of forensic specimens

— labelling, packaging and transporting of forensic specimens to maintain the chain of custody of the evidence

— therapeutic opportunities

— arranging follow-up care

Rape victims need an unusual degree of professional reassurance, acceptance and understanding in regard to the therapeutic examination . Dealing with patients who have been subjected to sexual violence thus demands a broad range of skills:

— a knowledge of normal human sexual responses, genito-anal anatomy and physiology

; — a knowledge of medical and colloquial terms for sexual organs and sexual acts;

— good communication skills; —

a basic knowledge of the dynamics of sexual violence;

— an understanding of the legal issues surrounding sexual crimes;

— an understanding of relevant cultural and/or religious issues;

— empathy and sensitivity.

initial assessment

On presentation, victims of sexual violence should be granted immediate access to a trained health worker. Their acute health care needs are the primary concern at this early stage and should be assessed as soon as possible. In busy settings where several patients may present simultaneously, such as hospital emergency departments, it will be necessary to sort out the order ofurgency in which patients are seen. Victims of sexual violence who have serious or life-threatening injuries will need acute medical or surgical care, as appropriate. Under these circumstances, the safety, health and well-being of the patient always takes priority over all other considerations. It may not always be possible to attend to the medical needs of patients with less severe injuries immediately; if a wait is unavoidable, patients should not be left alone in a waiting room, but should have someone with them to offer comfort and support until their medical needs can be attended to.

Use of insensitive language may contribute not only to patient distress during the examination but also hinder long-term recovery. Health workers are advised to choose words that are gentle and soothing; there is no place for judgmental or critical comments. It is imperative that all victims of sexual violence are treated with respect and dignity throughout the entire examination irrespective of their social status, race, religion, culture, sexual orientation, lifestyle, sex or occupation

You may find the following strategies and techniques helpful when dealing with victims of sexual violence:

● Greet the patient by name. Use her preferred name. Make her your central focus.

● Introduce yourself to the patient and tell her your role, i.e. physician, nurse, health worker. ● Aim for an attitude of respectful, quiet professionalism within the boundaries of your patient’s culture

. ● Have a calm demeanour. A victim who has been frightened and has experienced fear wants to be in the company of people who are not frightened

. ● Be unhurried. Give time.

● Maintain eye contact as much as is culturally appropriate.

● Be empathetic and non-judgmental as your patient recounts her experiences

General medical history

The primary purpose of taking a medical history is to obtain information that may assist in the medical management of the patient or may help to explain subsequent findings, e.g. easy bruising or loss of consciousness or memory loss. Health professionals are advised to refer to national guidelines or standards for conducting clinical examinations to ensure that they are in compliance. As a minimum, the medical history should cover any known health problems (including allergies), immunization status and medications. In terms of obtaining information about the patient’s general health status, useful questions to ask would be:

● Tell me about your general health.

● Have you seen a nurse or doctor lately?

● Have you been diagnosed with any illnesses?

● Have you had any operations?

● Do you suffer from any infectious diseases? When seeking information about medications that your patient may be taking, the following questions may be helpful:

● Do you have any allergies?

● Do you take tablets given to you by a health worker?

● Do you take herbal preparations?

● Do you take any other potions? If possible, a standard examination record (see Annex 1) should be used for recording details of the patient’s medical history; use of a standard form acts as a guide for the examiner by prompting relevant questions and prevents the omission of important details. Observing an experienced practitioner taking a history is also an invaluable aid in this area.

The assault itself

The main aims of obtaining an account of the violence inflicted are to:

— detect and treat all acute injuries; — assess the risk of adverse consequences, such as pregnancy and STIs;

— guide relevant specimen collection;

— allow documentation (the history should be precise, accurate, without unnecessary information that may result in discrepancies with police reports);

— guide forensic examination. When interviewing the patient about the assault, ask her to tell you in her own words what happened to her

. Document her account without unnecessary interruption; if you need to clarify any details, ask questions after your patient has completed her account. Avoid questions commencing with the word, “Why?” as this tends to imply blame; instead use open-ended, non-leading questions. Be thorough, bearing in mind that some patients may intentionally avoid particularly embarrassing details of the assault (for example, patients may omit details of oral sexual contact or anal penetration); others may find it difficult to talk about the assault.

\ Explain to the patient that you are interested in different aspects of the event to the police; as her health worker you are particularly concerned about any physical contacts between the patient and her assailant(s). Always address patient questions and concerns in a non-judgmental, empathetic manner; for instance:

— use a very calm tone of voice;

— maintain eye-contact as is culturally appropriate;

— don’t express shock or disbelief;

— avoid using victim-blaming statements such as, “What did you think would happen?”, “What were you doing out alone?”, “What were you wearing?” or “You should have known better.” Note that some victims experience involuntary orgasms during the assault; this may cause much confusion for the patient. The fact that a patient experienced orgasm does not imply consent. The following details about the alleged assault must be documented, peferably in an examination proforma :

— the date, time and location of the assault, including a description of the type of surface on which the assault occurred

; — the name, identity and number of assailants;

— the nature of the physical contacts and detailed account of violence inflicted;

— use of weapons and restraints;

— use of medications/drugs/alcohol/inhaled substances;

— how clothing was removed. Details of actual or attempted sexual activity should also be carefully recorded, in particular whether or not the following occurred:

The physical examination

When conducting a physical examination of a victim of sexual violence, examiners are advised to proceed as follows (further information on selected parts of the recommended examination sequence are provided in subsequent subsections as indicated):

1. Note the patient’s general appearance, demeanour and mental functioning. If the patient’s mental functioning appears impaired, attempt to assess whether the impairment is recent (e.g. due to the effects of alcohol) or symptomatic of a longer-term illness or disability (e.g. mental retardation).

2. Note the patient’s vital signs, that is her:

— blood pressure;

— temperature;

— pulse;

— respiration rate.

3. Examine the patient from head-to-toe, concluding with the genito-anal area respectively).

4. Note and describe in detail any physical injuries, even if forensic evidence is not being collected. Use body maps to indicate location and size of injury

. 5. Photograph any injuries, if possible . A separate consent form for photography may be necessary.

6. Order diagnostic tests (e.g. X-rays, CT scan, ultrasound) to aid in diagnosing.fractures, head and neck injuries, brain or spinal cord injuries, or abdominal trauma, as appropriate

. 7. Draw blood samples for testing for HIV (informed consent must be obtained for HIV testing), hepatitis B, syphilis and other STIs, as necessary.

4.evidences

The pattern of injuries sustained during a sexual assault

Falls during an assault or when fleeing from an assailant may produce a number of injuries. These will usually be abrasions or bruises (and occasionally lacerations) to the bony prominences (e.g. forehead, nose, elbows, knees, hips), with the severity of the injuries being proportional to the distance fallen.

fracture diagnosed from CT or MRI

facial expression o

• Agitation
• Anger
• Anxiety
• Confusion or disorientation
• Defensiveness
• Depression
• Fearfulness
• Helplessness
• Hesitant to talk openly
• Giving implausible excuses
• Non-responsiveness
• Withdrawn

This law purports to (1) protect the rights and interests of the elderly, and (2) provide the elderly with the support necessary to sustain the quality of life and dignity fitting to their respected status in community. The community shall protect and promote the health and mental well‐being of the elderly, and shall have the duty to represent and augment the lawful rights and interests of the elderly.