A home health nurse arrives at the residence of a client with paraplegia for a scheduled wound care visit. The client's spouse is pacing erratically and shouts, 'I cannot take care of this anymore!' The nurse notices three circular, crusted lesions resembling cigarette burns on the client's forearms. The client avoids eye contact and appears fearful. The spouse insists on remaining at the bedside. In what order should the nurse perform the following actions? Arrange the actions from first priority to last.
- 1Tactfully separate the spouse from the client by citing infection control protocols for the dressing change.
- 2Perform a thorough physical examination of the lesions and evaluate for any other signs of trauma.
- 3Ask the client directly and privately, 'Can you tell me how these injuries on your arms happened?'
- 4Record objective descriptions of the lesions, the client's exact statements, and the spouse's behavior in the medical record.
- 5Initiate a formal report of suspected dependent adult abuse to the appropriate state protective services agency.
Answer
The correct sequence prioritizes immediate safety and separation, followed by physical assessment, psychosocial interviewing, objective documentation, and finally, mandatory reporting.
In cases of suspected abuse, the nursing process prioritizes interventions based on safety and Maslow's hierarchy of needs. The absolute first step is to establish a safe environment by tactfully separating the client from the suspected perpetrator. Once safety is secured, the nurse addresses physiological needs by assessing the physical injuries. After physical assessment, the nurse addresses psychosocial needs by interviewing the client privately. Following the completion of the assessment, the nurse objectively documents all findings. Finally, using the gathered information, the nurse fulfills their legal obligation by reporting the suspected abuse to the designated authorities.
Step-by-Step Solution
Key Concept
Prioritization of Care in Suspected Abuse