Assessment

In suspected cases of abuse, the assessment includes a thorough history, physical examination, and functional, cognitive, and mental health assessments. The patient and the caregiver should be interviewed alone and separately (Abbey, 2009). Documentation begins with the description of the abusive or neglectful event, using the patient's words whenever possible. The duration, frequency, and severity of the abuse should be recorded. If injuries are present, a detailed description of the injuries and photographs, if available, should be documented. Assessment of functional dependence can be helpful in recommending resources, whereas evaluation of cognitive impairment is important in assessing both risk and capacity. The assessment should also include a mental health screening, with particular attention to depression, anxiety, insomnia, and alcohol abuse.

Weight loss Dehydration Poor hygiene

Traumatic alopecia Poor oral hygiene

Absent hearing aids, dentures, or eyeglasses Subconjunctival or vitreous hemorrhage

Hematomas

Welts

Burns

Bruises

Bites

Pressure sores

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