Which step should the nurse take immediately after documenting the locations of the bruises in the medical record?
While performing an assessment of a 75-year-old female in the emergency department, a nurse notes many bruises in various stages of healing on the client's body.
A. Notify the nursing supervisor. B. Notify the physician. C. Try to obtain more information from the client about when and how she acquired these bruises. D. Follow the facility s policy and procedures for reporting elder abuse.
Elderly abuse is common unfortunately and many personnel in emergency rooms may see signs of it. Some of these signs may be unusual behavior in regard to their injuries. They can’t or will not explain it. They may not be aware that they have been abused. If a 75-year old woman came into the emergency room for a medical procedure or reason, but the nurse notices bruises, she should take steps to find out what happened.
It is one thing to have just one bruise because that could happen to anyone for innocent reasons. However, if there are bruises that are in different stages of healing, then the nurse may be alarmed. She would need to start asking questions to the patient.
Try to obtain more information from the client about when and how they acquired the bruises and the use of diagnoses and drawings may be helpful. The nurse should not interpret wounds, but she should describe them.
Bruises result from the application of blunt force to the skin surface. Blood infiltrates the surrounding tissues from vessels that were ruptured during the impact. The larger the bruise, the longer it will take to heal. The nurse should also notify the physician.
Try to obtain more information from the client about when and how she acquired these bruises.-rationale: the nurse should try to obtain more information from the client to complete the assessment. without supporting information, she shouldnt assume the bruises indicate abuse, and she shouldnt notify her nursing supervisor until she has obtained additional facts. she should, however, inform the physician so he can examine the client. she should follow the facilitys policy and procedure for reporting abuse. the nurse should make a report if, after the assessment, she has a strong suspicion that abuse is the cause.client needs category: psychosocial integrityclient needs subcategory: nonecognitive level: applicationreference: weber, j., and kelley, j. health assessment in nursing, 3rd ed. philadelphia: lippincott williams & wilkins, 2007, p. 898.