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Medical-Surgical Nursing II · Chapter 12

The Safe Transition Desk

Elder mistreatment affects roughly one in ten community-dwelling older adults each year and only a small fraction is ever reported — and the transition out of hospital is where this population is most often harmed. Read the red-flag board and choose the action the law actually defines, build an SBAR that gets scored on completeness, hold the delegation line, and assemble a discharge that survives the drive home.
What you observed — tick everything that is true of this patient
Now choose your next action
Mrs. Alvarez, room 412, 84 years old, day 1 after hip fracture repair — put each line where it belongs
Escalation follows the same priority logic as the rest of med-surg: airway, breathing and circulation first, then unstable before stable, then acute before chronic.
Assign each task — assistive personnel, or you?
Building the discharge — tick what you will actually do
0Red flags on the boardTick what you observed on the left.
Forms of mistreatment your findings suggest
    Your action
    The rules that do not bend
    • Interview the patient alone. Create a legitimate reason to separate them — a scan, a bath, a specimen — and ask directly, calmly and without judgement: has anyone hurt you, threatened you, touched you in a way you did not want, taken your money, or failed to help you when you needed it? Do you feel safe where you live?
    • Document objectively: the patient’s own words in quotation marks, a body map, measurements, photographs per facility policy, and the caregiver’s behaviour as observed rather than interpreted.
    • Ensure immediate safety first — treat the injuries, and do not discharge into a suspected unsafe situation.
    • Report. In most United States jurisdictions nurses are mandated reporters; the threshold is reasonable suspicion, not proof. Reports go to Adult Protective Services, with law enforcement for immediate danger.
    • You do not investigate, and you do not confront the suspected abuser.
    • A cognitively intact adult with capacity may refuse services, and you may still be required to report. The two things are separate.
    Capacity is not competenceCapacity is a clinical, decision-specific judgement made at the bedside: can this patient understand the information, appreciate how it applies to them, reason through the options and communicate a choice? Competence is a global legal status determined by a court. A patient with dementia may lack capacity to manage finances and still retain capacity to refuse a feeding tube.
    —SBAR completenessSort the lines, then score it.
    0%
    What a complete call sounds likeA good SBAR is not a summary — it is a request. It tells the provider who and where in one sentence, what changed and what preceded it, what you measured, and exactly what you want them to order or do. If the provider has to ask you a question you already knew the answer to, the call was incomplete.
    The model call
    0/12Delegation boardAssign each task on the left.
    The boundaryAssistive personnel may take vital signs on stable patients, assist with hygiene, feeding, ambulation and toileting, apply non-skid footwear, reposition on a schedule, record intake and output, weigh the patient, and report observations to you. What may never be delegated is assessment, teaching, evaluation and any unstable patient.
    Why it matters in this populationThe aide can tell you that Mr. Beckett would not eat breakfast and seemed sleepy. Only the registered nurse can decide whether that is depression, hypoactive delirium, hypoglycaemia, a new opioid or an evolving sepsis — and only the registered nurse can act on it. Delegating the task never delegates the judgement.
    0Discharge readinessTick the elements on the left.
    These will send her back
      What each element buys
        Adapt the teaching, do not condescendAvoid elderspeak — the sing-song, high-pitched, diminutive-laden speech (“sweetie,” “honey,” “are we ready for our bath?”) that measurably increases resistance to care and communicates that the person is not an adult. Address patients by title and surname unless invited otherwise, and speak to the patient rather than the family member. For presbycusis, lower your pitch instead of raising your volume, face the patient in good light so your lips are visible, reduce background noise, and confirm hearing aids are in and switched on. For vision, print at 14-point sans-serif or larger with high contrast, avoid glare, and make sure glasses are clean and on. Cover one topic at a time, put the most important information first and repeat it last, and verify with teach-back: “I want to be sure I explained this clearly — tell me how you will take this new water pill when you get home.” A patient who nods and says “yes” has told you nothing.