Chapter 25: Family and Community Violence

Chapter 25: Family and Community Violence

Violence = social act of serious power abuse.

Typically involves a stronger person controlling/injuring a weaker person.

Most often directed toward the least powerful/most accessible individual.

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Examples

• Partner violence: one partner against the other

• Adult abuse: by non-spouse or non-partner

• Parent → child

• Child → parent

Cycle of Violence

Tension-Building Phase

• Minor episodes of anger, verbal abuse, minor physical violence (pushing/shoving).

• Both partners attempt to reduce tension.

• Perpetrator may use substances; victim minimizes violence.

• Victim feels tense, may blame self.

Acute Battering Phase

• Tension peaks → serious abuse occurs.

• Victim may provoke perpetrator to release tension.

• Victim may cover up injury or seek help.

• Most violent & shortest stage.

Honeymoon Phase

• Violence stops temporarily.

• Perpetrator apologizes, promises change.

• Victim hopes for change.

• Cycle repeats.

Periods of Escalation/De-escalation

• Time between violent episodes shortens without intervention.

• Emotions (fear, anger) intensify.

• Repeated violence → victim feels powerless.

Types of Violence

Toward family, stranger, or acquaintance (includes terrorism, mass-casualty events).

Natural disasters (hurricanes, earthquakes) → mental health effects comparable to violence.

Against mentally ill persons:

• More likely when risk factors present (poverty, homelessness, substance use).

• Mentally ill are more likely to be victims than perpetrators.

Violence between strangers: most predictive factor = history of violence & criminal activity.

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Physical Violence

• Physical pain or harm inflicted.

• Examples: shaken baby syndrome, strangling, striking, kicking, pushing.

Sexual Violence

• Sexual contact without consent (regardless of ability to consent).

Emotional Violence

• Behavior that minimizes self-worth or humiliates, threatens, or intimidates a family member.

Neglect (failure to provide)

• Physical care: feeding, hygiene.

• Emotional care: interaction/stimulation needed for normal development.

• Education: enrolling a child in school.

• Health/dental care as required.

Economic Abuse

• Failure to provide needs of a vulnerable person when funds are available.

• Unpaid bills → disconnection of utilities (gas, water, electricity).

Family and Community Violence Assessment

Forensic Nurse Role

• Special training in collecting evidence for suspected/actual sexual assault or physical abuse.

Nursing History – Interview Guidelines

• Ensure privacy.

• Be direct, honest, professional.

• Use simple, clear language.

• Be understanding & attentive.

• Use therapeutic techniques to show empathy.

• Ask open-ended questions (encourage descriptive responses).

• Inform client if referral must be made to child/adult protective services (explain process).

Family and Community Violence Risk Factors

Cultural Considerations

• Cultural differences affect validity of assessment data, client’s response, and appropriateness of nurse interventions.

Individual Risk

• Women = majority of victims (but men can also be vulnerable).

• Vulnerable persons at high risk when trying to leave the relationship.

• Pregnancy increases likelihood of partner violence (possibly due to stress, responsibility, or time demands).

• Older adults or dependent adults = vulnerable to abuse if in poor health, dependent, or disruptive.

  • Highest risk in families where violence already exists.

Family Groups

Violence occurs across all socioeconomic and educational levels.

Family violence = most common, aimed at family/friends > strangers.

Victims may include children, spouses/partners, or dependent adults.

Risk Factors for Child Abuse

Child is under 4 years old.

Child perceived as different (unwanted pregnancy, physically disabled, mentally impaired, or unique trait).

Vulnerable Person Characteristics

Low self-esteem, feelings of helplessness, hopelessness, guilt, shame.

Attempts to protect perpetrator or accept blame for abuse.

May deny severity of situation and display feelings of anger/terror.

Perpetrator Characteristics

Uses threats/intimidation to control vulnerable person.

Often an extreme disciplinarian who believes in physical punishment.

Poor impulse control.

Perceives victim as “bad.”

Violent outbursts.

Poor coping skills.

Low self-esteem, worthlessness.

Possible substance use disorder.

Difficulty with typical adult roles.

Often has a history of family violence as a child.

Age-Specific Assessments

Infants

• Shaken Baby Syndrome: intracranial hemorrhage, respiratory distress, bulging fontanels, ↑ head circumference, possible retinal hemorrhage.

• Any bruising in infants < 6 months = suspicious.

Preschoolers to Adolescents

• Unusual bruising: abdomen, back, buttocks (arms/legs bruises are more common from play).

• Bruising mechanism: inconsistent with history; multiple bruises at different healing stages = possible ongoing abuse.

• Bruises/welts: shapes resembling objects (belt buckle, cord).

• Burns: “Glove” or “stocking” pattern → forced immersion; small round burns → cigarette burns.

• Fractures: unusual (spiral fractures); multiple fractures suspicious.

• Bite marks present.

• Head injuries: altered LOC, unequal/nonreactive pupils, N/V.

Older & Vulnerable Adults

• Bruises, lacerations, abrasions, fractures inconsistent with history or mechanism of injury.

injury.

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome?

Select all that apply.

a

Sunken fontanels

b

Respiratory distress

c

Retinal hemorrhage

d

Altered level of consciousness

e

Increase in head circumference

b Respiratory distress

c Retinal hemorrhage

d Altered level of consciousness

e Increase in head circumference

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? 

Select all that apply.

a

Abrasions on knees

b

Round burn marks on forearms

c

Mismatched clothing

d

Abdominal rebound tenderness

e

Areas of ecchymosis on torso

b Round burn marks on forearms

e Areas of ecchymosis on torso

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Mismatched clothing is consistent with the child’s need for independence at this age.

Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

a

Refusing to pay bills for a dependent, even when funds are available, is neglect.

b

Intentionally causing someone to fall is an example of physical violence.

c

Striking a sexual partner is an example of sexual violence.

d

Failure to provide a stimulating environment for normal development is emotional abuse.

b Intentionally causing someone to fall is an example of physical violence.

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Refusing to pay bills for a dependent is economic abuse, rather than neglect.

Failure to provide a stimulating environment for normal development is neglect, rather than emotional abuse.

Nursing Care

Mandatory reporting laws: Nurses must report suspected child abuse or vulnerable adult abuse → civil & criminal penalties for failure.

Document subjective & objective data.

Provide basic care for injuries.

Make referrals as appropriate.

Develop safety plan (identify triggers, safe places).

Use crisis intervention techniques to stabilize families/communities after violence.

Community/Mass-Casualty Interventions

Early

• Ensure physical & psychological safety.

• Provide psychological first aid.

• Reduce stress manifestations (e.g., manage panic attacks).

• Restore rest & sleep; connect to social supports.

• Mental health nurses may provide:

  • Assessment & consultation

  • Therapeutic communication/support

  • Triage

  • Psychological & physical care

Critical Incident Stress Debriefing (Tertiary Crisis Intervention)

Used after traumatic events (e.g., school violence, violent death, natural disaster).

Phases:

• Introduce purpose of group

• Discuss facts of incident

• Share first thoughts and personal reactions

• List behaviors/physical changes since incident

• Teach stress management & coping techniques

• Provide closure, affirm participants, give referrals as needed

Occurs in group meetings with facilitator in safe environment.

Facilitator: acknowledges reactions, gives anticipatory guidance, teaches stress management, provides referrals.

Groups may meet ongoing or disband after resolution.

Client Education

Learn normal growth & development for children (parenting classes).

Develop problem-solving skills (e.g., assertiveness).

Learn positive stress management (relaxation, meditation).

Consider lifestyle changes that reduce stress (career change, relocation).

Interprofessional Collaboration

Encourage support group participation.

Use case management to coordinate medical, legal, social services.

Assist with client relocation if needed (safe house, shelter, foster care).

Refer to counseling/therapy (individual, family, group).

Provide information about community resources (child care, sitter programs, day-care, etc.).

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?

a

Advise the client about the location of safe houses and shelters.

b

Encourage the client to participate in a support group for survivors of abuse.

c

Implement case management to coordinate community and social services.

d

Educate the client about the use of stress management techniques.

a Advise the client about the location of safe houses and shelters.

Sexual Assault

Pressured/forced sexual contact, including:

• Sexually stimulated talk/actions

• Inappropriate touching/intercourse

• Incest, human sex trafficking

• Female genital mutilation

• Rape (forced sexual penetration)

Victims: male or female, including children & vulnerable adults.

Also includes: denial of emergency contraception, prevention of STI transmission, organized rape during war/conflict, sexual homicide.

Effects: Most survivors suffer long-term severe trauma.

• Rape-trauma syndrome = similar to PTSD, may develop after assault.

Rape

Nonconsensual sexual activity involving:

• Vaginal/anal penetration with body part or object

• Oral penetration by sex organ

Considered a crime of violence, aggression, anger, and power.

Types of Rape

Stranger

Marital

Date (acquaintance during a social engagement)

Acquaintance (majority of perpetrators are known to the victim)

Drug-Facilitated

• Alcohol & other substances often used.

• Substances cause sedation & amnesia in victims.

• Gamma-hydroxybutyrate (GHB): “G,” “liquid ecstasy”

• Flunitrazepam: “roofies,” “club drug,” “roachies”

• Ketamine: “black hole,” “kit kat,” “special K”

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

a

“Rape is a crime of passion.”

b

“Acquaintance rape often involves alcohol.”

c

“Young adults are the typical victims of sexual assault.”

d

“The majority of rapists are unknown to the victims.”

b “Acquaintance rape often involves alcohol.”

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Rape is a crime of violence, aggression, anger, and power.

Individuals of all ages are affected by sexual assault and can be male or female.

Sexual Assault Risk Factors

No “typical” description of a rape victim → can happen to any age group.

No “typical” survivor → effects vary widely, both physical & emotional.

Sexual Assault Rape Expected Findings

Rape-Trauma Syndrome

• Sustained, maladaptive response to forced sexual penetration.

Initial Emotional/Impact Reaction

• Expressed reaction: emotional outbursts (crying, laughing, hysteria, anger, incoherence).

• Controlled reaction: calm/blunted affect, confusion, difficulty making decisions, numbness.

Later Reactions

• Range of emotions: embarrassment, revenge, guilt, anger, fear, anxiety, denial.

• May persist, becoming maladaptive.

Somatic Reactions (later physical symptoms)

• Muscle tension, headaches, sleep disturbances

• GI symptoms: nausea, anorexia, diarrhea, abdominal pain

• GU symptoms: vaginal pain/discomfort

Acute Stress Disorder

Develops after traumatic event (e.g., sexual assault).

Symptoms like PTSD.

Lasts ≥ 3 days to ≤ 1 month.

If >1 month → classified as PTSD.

Posttraumatic Stress Disorder (PTSD)

Occurs >1 month after assault.

Symptoms:

• Reliving event (flashbacks, dreams, intrusive thoughts)

• Increased activity (avoiding places/people, moving residence)

• Hyperarousal (easily startled, anxiety, angry outbursts, insomnia, poor concentration)

• Avoidance/fears (fear of being alone, of sexual encounters, memory issues, guilt, depression)

• Functional impairment: low self-esteem, depression, sexual dysfunction, somatic symptoms (headaches, fatigue)

Compound Rape Reaction

Additional disorders can develop:

• Mental health disorders (depression, substance use)

• Physical disorders (illness manifestations worsened by trauma)

Silent Rape Reaction

Survivor tells no one (family, friends, or authorities).

Indicators:

• Abrupt changes in relationships

• Nightmares

• Anxiety during interviews

• Sudden changes in sexual behavior or phobias

• No verbalization of assault experience

Sexual Assault Nursing Care

Nursing Self-Assessment

• Nurse must remain empathetic, objective, nonjudgmental.

• If nurse feels too emotionally affected, another nurse should care for the client.

Client Assessment

• Assess level of anxiety, coping mechanisms, support systems.

• Screen for emotional and/or physical trauma.

Private Examination & Forensic Evidence

• Provide a private exam environment with a Sexual Assault Nurse Examiner (SANE), if available.

  • SANE conducts exam and collects forensic evidence (hair, swabs, blood, semen, genital/anal samples).

• National protocols require:

  • Documentation of biological & physical findings.

  • Evidence collection.

  • Ongoing follow-up assessments.

• Obtain informed consent (client can refuse evidence collection).

Legal & Emotional Support

• Provide safety assurance and empathy.

• Treat injuries and document.

• Avoid “Why?” questions. Emphasize: It’s not their fault.

• Support while evidence is collected; avoid adding to emotional distress.

• Assess for suicidal ideation.

Medical Care

• Administer prophylaxis for STIs (syphilis, chlamydia, gonorrhea, HIV, hepatitis).

• Provide emergency contraception.

• Evaluate pregnancy risk.

Therapeutic Interventions

• Encourage verbalization of the story and emotions.

• Use reflection, open-ended questions, active listening.

• Provide education about rape-trauma syndrome (short & long-term effects).

• Connect to support system (if client permits).

Sexual Assault Nursing Care After Discharge

Provide 24/7 hotline phone numbers for sexual assault survivors.

Promote self-care activities with written/verbal instructions.

Initiate referrals: counseling, therapy, support services.

Schedule follow-up visits at prescribed intervals.

Emphasize importance of aftercare

• Survivors often have poor compliance with follow-ups.

Provide interventions to reduce risk of long-term disability (depression, PTSD, suicidal ideation).