A practical nurse (PN) at an adult day care center is assisting a client with moderate Alzheimer's disease who arrives wearing an unusually heavy sweater on a warm summer day. Upon helping the client remove the garment, the PN observes multiple belt-shaped welts across the client's back. The client's family caregiver is currently waiting in the reception area. Arrange the following actions the PN should take in the correct order of priority.
- 1Ensure the client remains in a secure, private room separated from the family caregiver.
- 2Ask the client directly and gently how the injuries on their back occurred.
- 3Measure the dimensions and note the exact locations, shapes, and colors of the welts.
- 4Notify the facility nursing supervisor regarding the physical findings and suspected abuse.
- 5Document the objective physical findings and the client's direct quotes in the health record.
Answer
The correct sequence is to first ensure the client's safety by separating them from the caregiver, then ask the client about the injuries, measure and assess the welts objectively, notify the nursing supervisor, and finally document the findings.
In cases of suspected abuse, the practical nurse must follow a specific prioritization framework. First, the immediate safety of the client must be secured by separating them from the suspected abuser. Second, the nurse conducts data collection, starting with subjective data (asking the client privately) followed by objective data (measuring and assessing the injuries). Once data is collected, the nurse must urgently notify the nursing supervisor to initiate safety protocols and mandated reporting to protective services. Finally, after the client is safe and supervisors are involved, the nurse comprehensively documents the objective findings and direct quotes in the medical record.
Step-by-Step Solution
Key Concept
Prioritization of Care in Suspected Abuse