Abuse, Aggression, & Violence

Physical abuse findings

Body findings: bruising, lacerations, burn marks, fractured bones, puncture wounds, wounds in various stages of healing

General appearance: ripped or torn clothing, broken eyewear, disheveled hair and clothing

Perpetrators of physical abuse may use force, including kicking, hitting, slapping, pushing, strangling, or biting to control how others behave and think

Emotional abuse findings

- Changes in usual behavior, such as social withdrawal or non-responsive communication

- Loss of self-esteem

- Anxiety provoked by the presence of certain people

- Client's report ​​​​​​​of enduring verbal or mental mistreatment

The person responsible for abusing others may use threats, insults, and intimidation to exert control

Sexual abuse findings

- Sudden changes in behavior such as fear of people or places

- Sexually explicit behavior or sex play

- Regression to younger behaviors such as bedwetting

- Developmentally inappropriate interest in human sexuality

- Discomfort, bruising, or bleeding around the breasts, anus, or genital area

- Unexplained or recurring sexually transmitted infections (STIs)

- Underclothing that is damaged or contains bloodstains

- Client's report of being sexually assaulted

- Hard to set boundaries and protect themselves in future incidents

Any forced, inappropriate, or unwanted sexual contact and actual or threatened sexual violence is sexual trauma.

Digital media and online resources have simplified the grooming, luring, and exposure of children and adolescents to unwanted sexually explicit content.

Examples of this include photographs that are sexually explicit, indecent exposure, unwanted touching, rape, forcing individuals to engage in sexual acts, or coerced nudity.

Neglect or abandonment findings

- Unattended or untreated health problems

- Dehydration, malnutrition, untreated pressure injuries, and poor personal hygiene

- Hazardous living conditions (improper electrical work, no running water or heat)

- Poor living conditions (visible dirt, insect infestation, soiled bedding, fecal/urine smell, insufficient clothing)

- Desertion of a vulnerable individual

- Client's report of being abandoned or mistreated

May be unreported by elderly due to fear of being admitted into a nursing home.

Exploitation/economic abuse findings

- Sudden banking and accounting changes (unexplained withdrawals, transfers, or the addition of unauthorized names onto accounts)

- Abrupt changes in availability of funds, possessions, wills, or other financial documents

- Individual does not remember signing financial records

- Client's report of exploitation

Misuse of another person’s financial resources, with or without permission, is called exploitation or economic abuse. Examples of this include stealing, forging checks, promising to pay bills for a person but keeping the money for themselves, and falsifying wills or financial records.

What form of abuse is the hardest to identify?

Emotional abuse - no physical evidence is apparent

Aggression

- Actions intended to harm others are referred to as aggression and can be physical, psychological, or both

- While everyone may experience anger at one time or another, aggression is the deliberate attempt to harm or destroy and is referred to as hostile aggression

- Coercion and threats, intimidation, emotional abuse, isolation, denying/minimizing/blaming

Violent & Aggressive Behaviors

- Using exploitation of resources

- Using coercion and threats

- Using intimidation

- Using emotional abuse

- Using isolation

- Denying, minimizing, and blaming

- Using children

- Using privilege

Anger

- An intense emotion, can have positive and negative effects

- When managed, controlled, and expressed in an appropriate manner, anger can evoke positive changes within an individual

- Can result in hypertension, headaches, insomnia, and digestive issues, and potentiates the possibility of harm to self and others

- Anger may be displayed with cursing, sarcasm, yelling, breaking an inanimate object, or making a fist, but is not often followed by an aggressive act

Violence

Violence, such as murder, rape, or other forms of physical assault, is the ultimate form of aggression

More likely to act violently with the following disorders:

- Substance use disorder

- Traumatic brain injuries (TBI)

- PTSD

- Bipolar I disorder

- Impulse control disorders

- Attention deficit hyperactivity disorder (ADHD)

- Adverse childhood experiences (ACEs)

Risk factors associated with abuse, aggression, and violence

- History of violence

- Being the victim of a crime

- Witnessing abuse or violence

- Poor self-esteem and inadequate coping skills

- No presence of positive role models throughout childhood

- Adverse childhood experiences

Constant predictors of violence

- Inability to control aggressive impulses

- Not being able to understand the consequences of their actions

- Lack of remorse when interacting with others

- Substance use

Increase in this neurotransmitter has shown to increase anger and aggression...

Serotonin 5-HT

Etiology of aggression

Genetic

- MAO gene deficit to help balance serotonin levels

- Brunner syndrome → rare genetic condition that is characterized by impulsivity, aggression, mild cognitive impairment, and violence

Social determinants

- Cultural, socioeconomic, political, environmental, medical, and psychological

Medical conditions

- Damage to brain's prefrontal cortex, limbic system, and amygdala

Displacement

Redirecting troublesome or difficult thoughts to a safer person, animal, or inanimate object

Undoing

When an individual performs a behavior in an attempt to resolve unwanted thoughts or feelings associated with a previously completed behavior

Behaviors seen in clients prior to violent acts

- Declining to eat or drink

- Attempting to leave the area before discharge

- Verbally antagonistic toward staff or visitors

- Harming self

- Staring

- Pacing

- Destroying inanimate objects

Clinical presentation of a perpetrator

- Develops an excuse or rationalizes behavior

- History of substance abuse and aggressive behaviors

- Noncommunicative; no attempt to cooperatively develop a situation

- Uses intimidation to control others and as a means of temporarily resolving unwanted feelings or emotions

- Uses sex as a method to relieve unwanted thoughts or feelings, pornography

- Insecure about relationship; fear of relationship ending

Clinical presentation of a victim in violence

- Blames self as the reason for abuse and often reports feelings of guilt

- Feels like there is no resolution to behaviors

- Does not feel like financial or emotional independence is possible

- Lack of desire to engage in sexual behaviors and reports setting poor boundaries of sexual engagement with others

- Attempts to anticipate needs and desires in an effort to prevent tension in relationship

Child Abuse Prevention and Treatment Act (CAPTA)

Defines child abuse as "any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm"

- Abandonment primarily found in children, but applies to all ages including older adults

Intimate Partner Violence (IPV)

Phase 1: Build up - break down of communication, arguments, picking fights

Phase 2: Acute - battering begins, abusive acts, law enforcement may get involved

Phase 3: Honeymoon/reconciliation - perpetrator becomes affectionate and apologetic, maintains control over victim

Strategies to help prevent IPV

- Teach skills needed for healthy relationships to both youth and adults

- Empower peers to provide preventive strategies

- Provide early intervention and education to at-risk families/individuals

- Help create safer environments (school, workplace)

- Reinforce economic stability

- Intensify support to survivors

Elder Abuse

- The people experiencing neglect, abuse, or financial exploitation are often those who are more dependent upon others for daily care, including those with cognitive impairment, physical disabilities, and those with few friends or family members

- This dependency increases as the ability to care for oneself decreases over time, as seen in the older adult population

Rape and Sexual Abuse

- Rape includes forced sexual intercourse, including both psychological coercion as well as physical force

- Statutory rape is defined as an adult having sex with an individual younger than 18 years of age, even if the minor consents to the act

- Over two-thirds of rape survivors know the individual who has committed the attack

- Sexual assault is defined by various crimes that include actual or attempted attacks that involve unwanted sexual contact between survivor and offender

Survivors of rape need to remember that rape is always the fault of the perpetrator and never their fault

Stalking

- Unwanted attention, such as threats or harassment

- Frequently involving individuals know to the person being stalked

- 40% of people reported stalking before they were 25, and 60% of them have experiences actual threats of physical injury

Approaches used by stalkers include the following.

- Following and watching their target

- Obtaining entry into target's car or house and leaving items to let them know they can enter at anytime

- Showing up unannounced at target's home, workplace, or school

- Nuisance phone calls, emails, text messages, etc

Customary forms of bullying

- Kicking, hitting, tripping

- Teasing and name-calling

- Excluding targets from group or spreading rumors

- Destruction of property belonging to target

Core elements of bullying

- Repeated bullying behaviors

- Perceived or actual power imbalance

- Unwanted aggressive behavior

Bullying characteristics

- Students aged 12 to 18 who are bullied believe those who bullied them had more social influence, were physically stronger, had more money, or were able to influence what others thought of them

- Online bullying or bullying via text (cyberbullying) accounts for 15% of the instances of bullying among this age group

Strategies to prevent cyberbullying

- Paying attention to what is posted online and knowing who can see it

- Keep caregivers aware of online activities

- Tell an adult if you get a message that frightens you

- Keep your passwords secret from peers and friends but inform caregivers

- Always be kind online

Abuse survivors may ...

- Deny anything happened.

- Be fearful of what will happen to them once they leave the facility.

- Be wary of health care professionals.

- Demonstrate a lack of concern about their own needs.

- Be sleep deprived or malnourished

Interview techniques

- The interview should take place away from the suspected abuser

- The approach should be gradual and nonthreatening—more conversational than a barrage of questions

- Allow the injured party to have control during the process

- Do not touch the survivor without asking for permission to do so

- Traumatic effects such as memory loss, lack of focus, emotional reactivity, and multiple versions of a story may be exhibited during interviews and should be treated respectfully

Mandated reporters

When caring for vulnerable populations, including children, older adults, and individuals who have cognitive or emotional disabilities, reporting suspected abuse or violent acts is mandatory, and nurses are considered mandatory reporters

IM injections

B52: 50 mg diphenhydramine, 5 mg haloperidol, 2 mg lorazepam

- Can also use olanzapine, diazepam, chlorpromazine, midazolam, droperidol, lorazepam, promethazine, and ziprasidone

Nurse role in community violence

- Knowledge and skills to provide urgent care to those affected

- Awareness of events and ability to protect self

- Familiarity with where to find resources and help

Run-Hide-Run

- The first priority is to leave the area if at all possible and call 911

- If leaving is not an option, hiding is the next step, remembering to close and lock any available doors

- As a last resort, attempt to try to disable the intruder, preferably with others, or alone if necessary

Forensic Nurse

- A forensic nurse is a registered or advanced practice nurse who has received additional education specific to violence or victimization

- Provide consultation and testimony for civil and criminal proceedings relative to their findings

- May work with survivors of sexual assault or survivors of intimate partner violence (IPV), child maltreatment/abuse, older adult abuse, death investigations, or work in correctional facilities and assist following mass casualty events

Sexual Assault Nurse Examiner (SANE)

- Registered nurse who has advanced education in forensic examination of sexual assault survivors

- Responsibilities of a SANE include focused genital examinations, preserving specimens and collecting evidence, debriefing potentially traumatizing situations, and administering medications to treat or prevent sexually transmitted illnesses

- SANEs may provide expert testimony during legal proceedings

Abuse history assessment

- Previous occurrence of violent, abusive, or aggressive acts. This includes clients who have been exposed to abuse and aggressive/violent behaviors.

- Age and gender of client. Older adults are not as likely to engage in violence, and women are less likely to do so.

- Socioeconomic status. Clients in lower socioeconomic environments are more likely to act violently.

- Stress. Clients experiencing a loss, divorce, or unemployment within the past year

Contingency Management

Rewarding desirable behavior with quantifiable rewards

Restraint initiation

- Need a doctor's order (reason, length of time, type of restraints, criteria needed for removal)

- Five staff members to apply restraint to ensure safety (one for each extremity and one for head)

- Apply to upper extremities first then the lower extremities

- Supine position with one arm extended above their head and other arm at their side

Restraint assessment

- Patient evaluated by provider, RN, or PA within one hour

- Restrained clients should not be left alone

- Continuous monitoring (every 15 min) and documentation

- Observe for injuries, monitor for breathing difficulties, anticipate need for hygiene, hydration, toileting, intake, and comfort

- Assessment by RN hourly to include physiological and mental status, V/S (including pulse oximetry), review of circulatory status and skin integrity, and offering fluids

- ROM exercises every 2 hours

- Document all meds given

- All interactions with the client should encourage behavior that will promote release from seclusion and/or restraint

Debriefing

- Involves meeting with the client and other pertinent individuals to review, discuss, and document incidents that have occurred

- Always completed for clients that have been placed in seclusion or restraints as soon as possible following the discontinuation of the seclusion and/or removal of restraints

- Obtain permission from the client to include family members or other caregivers that may contribute to the debriefing session, as they can provide suggestions for adjusting the current treatment plan

Intentional dialogue during a debrief

- Discussion of any misperceptions

- Display of support for client's return to unit milieu

- Identification of different approaches to prevent subsequent seclusion/restraint

- Listening to the client's point of view

- Provide guidance to the client if they believe their rights have been violated

- Recognition of any trauma that occurred

- Adapt plan of care as needed