Topic 9: Child, Older Adult, and Intimate Partner Violence (Ch 28) and Sexual Assault (Ch 29)

physical abuse

the infliction of physical pain or bodily harm; consists of slapping, choking, biting, pushing, hitting, restraining, throwing, burning, etc

sexual abuse

any form of sexual contact or exposure without consent or in circumstances in which the victim is incapable of giving consent

emotional abuse

the undermining of a person’s self-worth; ie. constant criticism, humiliating, diminishing one’s ability, isolating, damaging relationships with others, name calling, and intimidating others

neglect

the failure to provide for physical, emotional, educational, and medical needs

economic abuse

controlling a person’s access to economic resources while making an individual financially dependent

crisis situation

a situation that puts stress on a family with a violent member

• consider their needs to be more important than anyone else’s

• look toward others to meet their needs

• have poor social skills

• describe their relationship with their partners as being the closest they have ever known

• typically lack supportive relationships outside the abusive relationship

what are characteristics of perpetrators (members of a household who is violent toward another member)

child abuse

any recent or failure to act on the part of a parent or caregiver that results in death, serious physical harm, sexual abuse, or exploitation; any failure to act that presents an immediate risk of serious harm can be either an act of commission or omission

acts of commission

a deliberate and intentional failure to act that presents an immediate risk of serious harm; ie. physical, sexual, and emotional abuse

acts of omission/neglect

occurs when a child’s basic physical, emotional, or educational needs are not meet, when a child is not protected from harm; includes physical, emotional, dental, and educational neglect, inadequate supervision, and exposure to violence

anxiety, depression, SI, health care issues, MDD, PTSD, poorer coping and social skills, increased risk of DID, poorer impulse control, major psychiatric distress

what are the secondary effects of child abuse

• being perceived as different due to temperamental traits, congenital abnormalities, or chronic disease

• juvenile offenders, runaways, violent criminals, prostitutes

• if the child reminds the patients of someone they do not like, such as an ex-spouse

• children who do not live up to the parents’ fantasy of what the child should be

• Children who are the result of unwanted pregnancies are at higher risk

• interference with emotional bonding between parents and child due to premature birth or prolonged illness requiring hospitalization

what are the RF of childhood abuse

• a history of abuse, neglect, or emotional deprivation as a child

• family authoritarianism

• low self-esteem, feelings of worthlessness, depression

• poor coping skills

• social isolation, may be suspicious of others

• involved in a crisis situation

• unrealistic expectations of a child’s behavior

• frequent use of harsh punishment

• history of severe mental illness, such as schizophrenia

• violent temper outbursts

• expects the child to satisfy needs for love, support, and reassurance

• projection of blame onto the child for parents’ troubles

• inability to seek help from others

• perception of the child as bad or evil

• history of drug or alcohol misuse

• a feeling of little or no control over life

• low tolerance for frustration

• poor impulse control

what are characteristics of abusive parents

intimate partner violence

abuse where one partner asserts power and control over the other; includes physical violence, rape, stalking, and psychological aggression by a current or former partner and the relationship is about control, power, and instilling fear

• men who believe in male dominance and have the need to be in charge

• pathological jealousy: refuses to allow partners to work outside the same place, damages their work in the same place, accompanies them to and from activities, forbids them from having personal friends or participating in activities outside the home

• controlling finances and expenditures

• pregnancy

• alcohol and other drugs

• when a woman makes a move toward independence: getting a job, visiting friends without permission, going back to school

• victims threaten to or actually leave the relationship

what are RF for intimate partner violence

tension-building, acute/serious battering, honeymoon

what is the cycle of violence

tension-building stage

• begins with minor incidents, such as pushing, shoving, and verbal abuse

• the victim often ignores or accepts the behavior due to fear of escalation and then the abusers rationalize that their behavior is acceptable

• as the tension builds up, both may try to reduce it

• the abuser may try to reduce the tension with the use of alcohol/drugs and the victim may try to minimize the incidents

• the abuser is edgy, has minor explosions, may become verbally abusive, minor hitting, slapping, and other incidents begin

• the victim feels tense and afraid like “walking on eggshells,” feels helpless, becomes compliant, accepts blame

acute/serious battery stage

• the tension peaks and becomes unbearable

• is usually triggered by an external event or by the abuser’s emotional state

• the victim may provoke an incident to get it over with

• victim may try to cover up the injury or may look for help

honeymoon stage

• the abuser demonstrates kindness and loving behaviors

• initially feels remorseful and apologetic, so may bring presents, make promises, and tell the victim how much they are loved and needed

• victim becomes trusting, hopes for a change, and wants to believe the partner’s promise

older adult abuse

intentional actions that cause harm or create a risk of harm to an older, vulnerable person, failing to provide for the adult’s basic needs or protect them from harm that can occur from a family member, custodian, care facility personnel and can be physical, emotional, financial, sexual, neglect, or self-neglect

• >75 years old (highest RF)

• females and Caucasians

• poor mental or physical health

• disruptive disorders like Alzheimer’s

• high dependency needs

• living with a relative

• if they abused their children, who are now taking care of them/if the abused spouse is now the caregiver

what are RF of older adult abuse

• screen all patients for possible abuse

• symptoms may be vague and include chronic pain, insomnia, hyperventilation, or gynecological problems

• include questions to elicit a history of sexual abuse, family violence, and drug use/abuse

• complete assessment with the victim alone

• sit near the patient and spend some time establishing trust and rapport before focusing on the details of the violent experience

• better to ask about ways of solving disagreements or methods of disciplining children rather than use the words abuse or violence

• use the term partner when asking bout the relationship

• allow the victim to tell the story without interruption, ask open ended questions, be direct, honest, professional, understanding, and attentive

  • tell me what happened to you, who takes care of you, what happens when you do something wrong, how do you resolve disagreements, what do you do for fun, who helps you with your kids/parents, what time do you have for yourself

  • what arrangements do you have when you have to leave your child, how do you discipline your child, when your infant cries how do you get them to stop, what about your child’s behavior bothers you the most?

• assess for types of abuse

• use language that the patient understands

• inform if you have to refer to Children’s/Adult protective services

• have patient clarify words not understood

• ensure their client’s safety and well being

what does assessment for those experiencing abuse, aggression, and violence include

series of minor complaints such as HA, back troubles, dizziness, and accidents, especially falls

what are covert signs of physical abuse

bruises, scars, burns, wounds in various stages of healing particularly around the head, face, chest, arms, abdomen, back, buttocks, and genitalia

what are overt signs of physical abuse

• covert/overt signs

• Explanation does not match the injury seen or is vague

• minimizes the seriousness of the injury

• any bruises on an infant younger than 6 months old/FAS/Shaken baby syndrome

• ask directly in a nonthreatening manner if someone close to them has caused the injury to observe for response such as hesitation or lack of eye contact

what are indicators/signs of physical abuse, how do you assess physical abuse

shaken baby syndrome

the leading cause of death as a result of physical abuse that usually occurs in children younger than 2 years old; injuries are a result of the brain moving in the opposite direction as the baby’s head which can lead to respiratory problems, bulging fontanels, retinal hemorrhages, and CNS damage resulting in seizures, vomiting, and coma

fetal alcohol syndrome (FAS)

prenatal exposure to alcohol that results in brain damage and growth problems

neonatal abstinence syndrome (NAS)

irritability in infants, difficulty soothing, and long-term health and development problems such as hearing, vision, and learning difficulties that can last for days to weeks

• sexualized behavior in children

• precocious knowledge

• drawing sexually explicit images

• demonstrating sexual aggression

• acting out sexual interaction in play

• masturbation

• sexual promiscuity

• symptoms of PTSD: nightmares, somatic complaints, feelings of guilt

• emotional, behavioral, and physical consequences

• depression, anxiety, suicide, aggression, chronic low self-esteem, chronic pain, obesity, substance misuse, self-mutilation, PTSD

what are signs of sexual abuse

• low self-esteem

• feelings of inadequacy

• anxiety

• withdrawal

• learning difficulties

• poor impulse control

• is less obvious and more difficult to assess than physical violence

what are signs of emotional abuse

• undernourished

• dirty

• poorly clothed

• inadequate medical care

• lack of immunizations

what are signs of neglect

• failure to provide when adequate funds are available

• unpaid bills, resulting in disconnection of the heat or electricity

• victim is unable to pursue an education or find a job, ensuring dependency

what are signs of economic abuse

• do not try to “prove” abuse by accusations or demands

• do not display horror, anger, shock, or disapproval of the perpetrator or situation

• do not place blame or make judgements

• do not allow the patient to feel “at fault” or “in trouble”

• do not probe or press for answers the patient is not willing to give

• do not conduct the interview with a group of interviewers

what should a nurse NOT do when assessing a patient for abuse, aggression, and/or violence

• verbatim statements of who caused the injury and when it occurred

• a body map to indicate size, color, shape, areas, and types of injuries, with explanations

• physical evidence of sexual abuse, when possible

• ask the patient to return in a day or two for more phots as bruises may be more evident at that time

• assure the patient confidentiality of the record and of its power should legal action be initiated

• even if the interventions does not occur at this time, begin the record

what does documentation include when/after assessing a patient for abuse

• agitation and anxiety bordering on panic

• remain vigilant and unable to relax/sleep due to living in fear

• HTN, irritability, GI disturbances

• hesitation, lack of eye contact, use of vague statements

• are in a dependent position

• suicide may feel like the only option to leave

• may self medicate with alcohol or drugs to escape the situation

what things/signs are commonly present in those experiencing violence

coping mechanisms

often prevent the termination of the relationship and may take the form of flawed beliefs/myths, feelings of confusion, shame, despair, and powerlessness

• responsiveness to infants’ signals

• caregiver facial expression in response to infant

• playfulness of caregiver with infant

• nature of physical contact during feeding and other caretaking activities

• temperament of the infants

• caregiver’s history of harsh discipline or abuse as a child

• parental attitudes: feelings of inadequacy as a parent, unrealistic expectations of a child, fear of doing something wrong, attribution of negative qualities to newborn, misdirected anger, continued evidence of isolation, apathy, anger, frustration, projection, adult conflict

• environment: sleeping arrangements, child and home management, use of supports (formal and informal)

• need for immediate services for situational emotion educational info about hotlines, babysitters, homemakers, parent groups, child development, childcare, home management services

what are factors to assess during a home visit for a child

• absence or lack of access to basic needs like food, water, and meds

• unsafe housing

• lack of or inadequate utilities, ventilation, or space

• poor physical hygiene

• lack of assistive devices such as hearing aids, eyeglasses, and wheelchairs

• medication management: outdated prescriptions, unmarked bottles

what are factors to assess during a home visit for an adult

• bleeding injuries, especially to the head and face

• internal injuries

• concussion

• perforated eardrum

• abdominal injuries

• severe bruising

• eye injuries

• strangulation marks on the neck

• back injuries

• broken/fractured jaw, arms, pelvis, ribs, clavicle, legs

• burns from cigarettes, appliances, scaling liquids, and acids

• psychological trauma, anxiety, attacks of hyperventilation, heart palpitations, severe crying spells, SI

• miscarriage

what are common presenting problems of victims of abuse in the ED

• perforated eardrum

• twisted or stiff neck/shoulder muscles

• HA

• depression, anxiety

• insomnia, violent nightmares

• extreme fatigue

• eczema

• loss of hair

• talk of having problems with husband or son, describing them as jealous, impulsive, or an addict

• repeated visits with new complaints

• bruises of various ages and specific shapes (fingers, belts)

what are common presenting problems of victims of abuse in ambulatory care settings

• Nurses are legally mandated to report suspected or actual cases of child and vulnerable adult abuse

• provide a trained interpreter as needed

• support the victim

• counsel about safety

  • develop a plan for rapid escape when abuse occurs that includes a destination, transportation, money, bag packed hidden where the abuser cannot find it, and own savings account

  • identify signs of escalation and violence

• facilitate access to other resources when appropriate

• safety interventions when the relationship is over

  • change the locks, install steel/metal doors, security system, smoke detectors, and an outside lighting system

  • inform others that they are no longer together and police should be called if they are seen near the home/children

  • give names of those allowed to pick up the kids

  • change phone number, have someone screen calls

  • avoid places that they went together

  • obtain a protective order

• educate on items to take when leaving

  • ID, birth certificate, SSN, driver’s license, passport, welfare ID

  • school and medical records, meds

  • money, bank books, credit/debit cards

  • keys to house, care, office

  • clothes

  • lease/rental agreement, house deed, mortgage payment books, current unpaid bills

  • insurance papers

  • pictures, jewelry, items of sentimental value

  • children’s favorite toys and blankets

  • address book

what are the nursing interventions for abuse

primary prevention

consists of measures taken to prevent the occurence of abuse, which includes identifying individuals and families at high risk, providing health teaching, and coordinating supportive services to prevent crisis by:

• reducing stress

• reducing the influence of risk factors

• increasing social support, coping skills, and self-esteem

secondary prevention

Involves early intervention in abusive situations to minimize their disabling or long-term effects, such as:

• screening programs for those at risk

• medical treatment of injuries

• coordinate community services to provide continuity of care

• reduce stress and depression by providing supportive therapy, support group, pharmacotherapy, and contact info for community resources

• social dysfunction or lack of information can be addressed by counseling and education

• Caregiver burden can be reduced by arranging assistance, housekeeping, or placing the patient in a more appropriate setting

tertiary prevention

involves nurses facilitating the healing and rehab process by counseling individuals and families, providing support for groups of survivors, and assisting survivors of violence to achieve their optimal level of safety, health, and well-being

includes legal advocacy programs for survivors of intimate partner violence

individual therpy

• provides empowerment, allows one to recognize and choose productive life options, and develop a sense of self

• can address symptoms of depression, anxiety, somatization, or PTSD in those who have experienced abuse

group therapy

• provides reassurance that one is not alone and change is possible, using cognitive behavioral techniques

• can diminish feelings of isolation, strengthen feelings of self-esteem and self-worth, and increase the potential for realistic problem solving in a supportive atmosphere

date rape

nonconsensual activity with a dating or romantic partner

alcohol

the most frequently used date-rape drug

gamma-hydroxybutyric acid (GHB)

a date-rape drug that affects the CNS and is dangerous when mixed with alcohol or other CNS depressants and clears from the body extremely quickly (within hours) so it is hard to detect

onset within 5-20 minutes and can last for 1-12 hours

what is the onset and duration of gamma-hydroxybutyric acid (GHB)

• anterograde amnesia

• relaxation

• euphoria

• disinhibition

• incoordination

• confusion

• deep sedation

• tolerance and dependence are exhibited by agitation, tachycardia, insomnia, anxiety, tremors, and sweating

what are the effects of gamma-hydroxybutyric acid (GHB)

• respiratory depression

• seizures

• N/V

• bradycardia

• hypothermia

• agitation

• delirium

• unconsciousness

• coma

what are the s/s of an overdose of gamma-hydroxybutyric acid (GHB)

• intubation for severe respiratory distress

• atropine for bradycardia

• benzos for seizure activity

• induce vomiting when possible

what are the treatment for an overdose of gamma-hydroxybutyric acid (GHB)

flunitrazepam (Rohypnol)

a potent benzo that is 10x stronger than diazepam and is the classic “roofie” drug that causes retrograde and anterograde amnesia that is not approved in the US for any use

onsets within 10-30 minutes and lasts for 2-12 hours

what is the onset and duration of flunitrazepam (Rohypnol)

• more potent when combined with alcohol

• sedation

• psychomotor slowing

• confusion

• dizziness

• impaired coordination

• muscle relaxation

• amnesia

• overdose is unlikely

what are the effects of flunitrazepam (Rohypnol)

• airway protection

• GI decontamination

what are the treatment for flunitrazepam (Rohypnol)

ketamine

An anesthetic, that is cautiously used as a procedural sedative in medical and vet settings due to hallucinogenic, psychedelic, and dissociative properties

• dream-like state leading to anterograde amnesia and complete compliance of the victim

• confusion

• paranoia

• delirium

• combative

• drooling

• hallucinations

• respiratory depression and arrest

• death

• anxiety, tremors, numbness

• nausea

what are the effects of ketamine

• airway maintenance

• anticholinergic: atropine and benzos

what does treatment for ketamine include

• gather as much objective data as possible

• assess level of anxiety, coping mechanisms, available support systems, S/S of emotional and physical trauma

• those experiencing severe to panic levels of anxiety will not be able to solve problems/process information, so provide support, reassurance, and appropriate therapeutic techniques to lower anxiety and facilitate mutual goal settings and the assimilation of info

• ensure the client’s safety and well being

• assess physical trauma

what does assessment for a patient that has been sexually assaulted include

• advise the victim to report any signs of pain or discomfort immediately

• inspect and palpate for any signs of injury

• Physical signs can include injuries to the face, head, neck, extremities, and anogenital areas

• document size, color, description, and location of injury both in narrative and pictorial form, using preprinted body maps, hand drawn copies, or photos

• collect blood, hair samples, oral swabs, nail swabs/scrapings, anal/genital/penal swabs

• take a gynecological history

• perform in order of head to toe, detail genital exam, evidence collection and preservation, documentation, treatment, discharge planning, and follow-up care

• patient has the right to decline parts, informed consent must be provided and forms signed

• provide prophylactic STD treatment as needed

what does assessing a patient physical trauma after sexual assault include

• are a priority in triage

• do not leave alone

• provide privacy

• receive psychological support, medical care, documentation of pertinent history, and a thorough physical exam

what should happen when a sexual assault victim arrives in the ED

sexual assault nurse examiner (SANE)

A nurse with specialized training in caring for sexual assault clients has demonstrated competency in conducting medical and legal evaluations, and can be an expert witness in court, and provides care to clients who have been sexually assaulted

• performs physical exam

• collects forensic evidence

• provides expert testimony and forensic evidence

• provides support for the psychobiological needs of survival

• accurate and meticulous documentation

• MDD, anxiety, fear, suicide

• difficulties with daily functioning, low self-esteem, sexual dysfunction, and somatic (physical) complaints

• recurrent and intrusive memories, dreams, flashbacks, psychological/physiological distress

• dissociative symptoms may alter the sense of reality and result in the inability to remember (amnesia) parts of the traumatic event

• avoidance of situations, places, events, or objects that remind them of the experience

• hyperarousal, being easily startled, anxiety, angry outbursts

• depersonalization, derealization

• negative self-image, depression, eating disorders, personality disorders, self-destructive behavior, substance misuse

what effects can sexual assault have on the victim

rape trauma syndrome

compound reaction that includes the acute phase of disorganization and the long-term recovery phase; includes shame, guilt, helplessness, powerlessness, dependence, low self-esteem, depression, mood swings, aggression, anger, agitation, revenge, substance misuse, suicide attempts, anxiety, fear, disturbed sleep, nightmares, sexual dysfunction, muscle tension, hyperalertness, dissociation, disorganization, shock, confusion, phobias, paranoia

• provide a safe and private environment upon arrival in the ED, with access to a community-based advocate

• use trauma-informed care throughout

• provide consistent, objective, immediate medical care as well as an option for the collection of evidence

• consult with SANEs

• attend to physical needs and injuries

• offer emergency contraception

• screen for HIV, hep B, and syphilis

• administer prophylactic treatments for STDs

• immunize for tetanus if there are abrasions and >5 years since last immunization

• crisis counseling/psychotherapy

• Report suspected abuse as appropriate

• provide follow-up at least 2, 4, and 6 weeks post-initial eval to assess for psychological progress, presence of STDs, and pregnancy

what are nursing interventions for patients who have been sexually assaulted

• reporting requirements vary by state and age of victim

• follow facility policies and procedures

• involve forensic experts and SANEs if possible

• many STIs are mandated to be reported

• maintain confidentiality as much as possible to protect the victim, but still arrange necessary supports

what are the reporting obligations and ethical issues for sexual assault patients