Patients with Disabilities

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1 Dr Kim Curran, DNP, FNP-BC, SANE-A, SANE-P Meriter Hospital One of the most underdiagnosed problems in society Victims often reluctant to reveal abuse: Might be due to shame, self blame, denial, dear, desire for privacy APS might be altered to most visible cases however many go undiscovered Domestic violence Seen as a private matter Mostly due to power and control not stress of caregiver Screening for Elder / Vulnerable Adults What does the literature say for healthcare? Meriter Hospital SANE Program Patients with Disabilities Pts with Disabilit ies Basics of Wound Healing Acute wounds have an easily identifiable mechanism of injury with skin integrity disrupted typically due to some form of trauma. Can result from blunt or penetrating mechanisms (gunshot, animal bite) and an array of wound sizes, depths, and locations can result. Simple or complicated lacerations, abrasions, burns and significant tissue defects can occur.

2 Diabetes is a particularly important risk factor for the development of chronic wounds Neuropathy associated with diabetes affects sensory, motor, and autonomic nerves. Over 100 known cytologic factors contribute to impaired wound healing in patients with diabetes 1%7E150&source=see_link&search=diabetes+and+wound+healing&utdPopup=true Malnutrition Cancer Chemotherapy, Radiation Asthma / COPD Chronic steroid use Alcoholism The detrimental effect of smoking on wound healing is multifactorial, including vasoconstriction causing a relative ischemia of operated tissues, a reduced inflammatory response, impaired bacteriocidal mechanisms, and alterations of collagen metabolism. ASA Main adverse effect of ASA is increased risk of bleeding. NSAID Ibuprofen Aleve Arthritis medications Clopidogrel Afib Post MI, Stroke Warfarin Afib / aflutter Post PE Post cardiac surgery; valve replacement Injury

3 Elders respond differently from younger individuals in their response to injury Several forensic biomarkers may help evaluate elder abuse Abrasions Lacerations Bruising Fractures Often the bi product of trauma. Hip and wrist most common Restraints Burns Sexual abuse Contusions (Bruising) Associated with rupture of small blood vessels under the skin without breaking the skin, discoloration of area Generally with age blood vessels can rupture more readily No consistent way to date a bruise Nothing in the medical literature is consistent Will vary greatly based on age, nutritional status, and medications Mechanism Abuse Not Abuse Blunt force Crush Punch (closed fist) Kick (with or without foot wear) Pinch / grab Bite Bullseye s Injury Bump into furniture Fall onto knees Child bite Pattern bruising shape of familiar object(s) Knuckles, fingers, mouth, etc If the force applied is great enough you will see the outline of the object, high velocity injury rarely an accident. Ex: Hand slap 68 year old female 64 year old female

4 Multiple stages of healing (many different colored bruises) Bruises on breasts / genitals Bruises to areas not commonly struck Bruises not over a bony area of body (abdominal bruising rarely an accident) Story with how obtained not consistent with bruising Clusters of bruises on one area If your client is bed / wheelchair bound, how are they bruising? Document shape, color, size of injury 87 female over 100 bruises (breast photo) Red Flag injury on buttock. 72 year old female Consistent with crush injury, most likely pinch or grab based on pattern Abrasions Very common on exposed skin Caused by friction Pulling or dragging across a floor Finger nail marks (crescentic in appearance)

5 55 year old male cognitive delay 19 year old reports dragging across carpet by caregiver Lacerations Self inflicted incised wounds. Lacerations are noted to be tears of the skin resulting from blunt trauma Skin tears common form of laceration in elderly, found commonly: forearms, lower extremities. Can be accidental from the pulling off of tape / bandage. Can also be abuse: a punch or a restrain Incised Wounds Typically from a sharp object such as a knife. May be accidental, self harm behavior Incised wound, stabbing

6 Multiple punches to the nose and eye. Noted laceration on bridge of nose, most common spot to lacerate due to nasal bone. Punch to head multiple times Accident vs Intentional Contact Burn Accident Splash marks Varying depth of burn Indistinct borders Burns in flexion creases Intentional Splash marks (rare) in children however in adults throwing liquid common Uniform depth of burn Very distinct borders Buttocks, perineum, extremities Characteristic spared areas (ex, flexion creases) Accidental: Burn is typically smaller and of irregular depth Inflicted: Held against object, typically a deeper, uniform burn Often in less exposed areas

7 Elder and Adult Typically occurs As estrogen levels falls: Labia size decrease Uterus and ovaries diminish in size Loss of elasticity of breast tissue Loss of fatty tissue deposits in labia Pubic hair thins Decreased lubrication of vagina due to Bartholin gland reducing in activity Vaginal walls are pale, appear paper thin, dry, become thinner, and lose some capacity for expansion Genital trauma Much more likely and more severe in elders Even minor trauma may cause significant discomfort Ask about difficulty or painful urination Inner thigh bruising Bleeding Oral trauma Bruising of the uvula / palate Lesions in the mouth (new) or cross the lip line (new) STI (new diagnosis) Behavior Change Anger, depression, fear, withdrawal, difficulty sleeping, increase aggressive behavior Labia fold laceration 68 female with DM 83 year old post admission

8 Giardino, A., Datner, E., and Asher, J. Sexual Assault Victimization Across the Life Span a Clinical Guide Green, D. (2015). Safeguarding and protection of vulnerable adults. Nursing & Residential Care, 17(5), Lynch, V. and Duval, J. Forensic Nursing Science (2 nd ed) Moyer, V. A. (2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: u.s. Preventive services task force recommendation statement. Annals Of Internal Medicine, 158(6), doi: / Watson, E. (2013). Elder Abuse: Definition, Types and Statistics, and Elder Abuse (Mistreatment and Neglect) Laws. Journal Of Legal Nurse Consulting, 24(2),