Chapter 55. Nursing Care of a Family in Crisis: Maltreatment and Violence in the Family

maltreatment

(abuse) willful injury by one person of another

• can be physical, emotional, neglectful, sexual maltreatment or intimate partner violence

permissive reporter

encouraged but not required to report and can be anyone who witnesses maltreatment

mandatory reporters

will report specifics and factual information based on what is observed not perceived/interpreted

• good faith provision - need to tell parents you are reporting

• nurses, MDs, law enforcement, social workers, teachers

theories of child maltreatment

• special parent: parent has potential to maltreat a child

  • someone has a lot of anger or range

  • child is not their own biologically

• special child: a child viewed as “different” in some way by the parent

  • learning disability

  • congenital deformity

  • ill child

• special circumstance:

  • event occurs

  • keep in mind cultural differences

watch for signs such as spiral fractures (grab and twist), variously staged healing injuries or bruises, injuries that don’t match the developmental level

bruises on babies are bad but Mongolian spots on sacral lower back/buttocks are normal birthmarks with various ethnic groups

measures to prevent maltreatment or intimate partner violence

• advocate for courses on parenting and on growth/development of children so parents understand whether or not child is able to meet expectations based on growth and development to limit frustration (literally unable to and are not supposed to be able to)

  • may be doing something based on how they were raised and the expectations their parents had for them

• help children learn problem solving techniques

  • do they don’t have tantrums and lead parents to get more frustrated

• foster high esteem in children and women

  • empower them and give them a voice so they are comfortable enough to talk

• responsible reproductive planning

  • financial situation

• parental support groups if single parent is struggling and don’t have a lot of resources

  • can meet similar people and assist each other

  • learn of resources

• role modeling

  • demonstrate healthy communication

• identify “special” children and parents who were maltreated

  • special children can also be the parents - family history

questions to ask parents for potential maltreatment

• ask about parent enjoyment of role

• establish eye contact

• how do they communicate with the baby - are needs expressed as demands?

• negative verbalizations - disappointed at the baby’s sex or the appearance of the child

• expectations beyond the developmental level of the child

• attentive to infant demands?

• reaction to parenting tasks

• sibling/spousal jealousy/parental jealousy

• care of child in in the office - are they involved or passive

• do parents report non-existent symptoms

types of child maltreatment

abusive head trauma

• whiplash injury to neck, edema to brainstem, possible subdural hemorrhage, distinctive hemorrhages to retina

• often seen with shaken baby syndrome

ritual maltreatment

• physical, sexual, or psychcological maltreatment with bizarre or ceremonial activities

physical neglect

• unwashed, thin and malnourished or dressed inappropriately for conditions

psychological maltreatment

• most difficult to detect

• may occur only at home

• effects may be subtle

factituous disporder

• symptoms reported by parents not easily detected by physical exam and present only when the person initiating the symptoms is providing care

• sometimes do things to cause symptoms

• munchausen syndrome by proxy

failure to thrive

• lethargy, poor muscle tone, loss of subcutaneous fat, skin breakdown, lack of resistance to examination, greater reluctance to reach for toys or initiate human contact, staring hungrily at people as they approach, delays in siting and pulling to standing position/crawling/walking, markedly delayed or absent speech, rocking on all fours excessively, diminished or nonexistent crying, little cuddling or conforming to be held

sexual maltreatment

• molestation

• incest

• pornography or prostitution

• statutory rape

• sexual assault

• date rape

• intimate partner violence (punching, slaps, verbal → more frequent → beatings → fractures)

assessment for maltreatment

missing patches of hair, head trauma, retinal hemorrhages, cigarette burns (typically in patterns), burns on dorsal part of hand not a typical accident for a child, feet being placed in hot water as punishment → sock burns, nail-biting or anxiety behaviors, bruises that don’t match story

• sexual maltreatment: reports of sexual activity with an adult, demonstrate awareness of sex or sexual vocabulary beyond age of expectation, participates in sexual expression with dolls, child younger than 15 with an STI or pregnant, perineal/vaginal/anal exam reveals inflammation or vaginal tears/anal fissures, history of symptoms with increased anxiety, change in school performance, school phobia, truancy, voices fear of being left alone with certain people, reports vague abdominal pain or demonstrate acting-out behavior (hurting themselves or trying to get negative attention to avoid certain people or situations)

• rape trauma syndrome: combination of humiliation, shame, guilt, embarrassment, anger, vengefulness, tremble, in pain, startle visibly at sound or touch of others, reoccurring nightmares, sexual dysfunction, inability to relate to opposite sex

  • burns, lacerations, bruises, head injuries

  • ask people to account for all bruises and whether they have ever been concerned about their safety or well-being

therapeutic management for child maltreatment

• prevent further maltreatment

• provide consistent care and support for the maltreated child

• evaluate and promote family heath

• psychological counseling for both individuals

  • child to improve self-esteem

  • adult to channel sexual expression to less destructive outlets

• follow-up care best done by someone who saw child initially

• treatment for STIs or protection against pregnancy as needed

• emergency care for rape

  • DOCUMENTATION: whether victim bathed or washed before coming for care; whether victim was menstruating or using a tampon; quote victims exact words when possible; describe appearance in unbiased detail-including presence of bruises, lacerations, abrasions, and clothing; nurses may be asked to testify in court about victim’s appearance after the assault although documentation in the record is usually all that is necessary

  • oral washing, fingernail scraping, blood venereal disease draw, HIV and hepatitis B surface antigens, pregnancy test, hair samples, vaginal smear for sperm and DNA, gonococcus smear, vaginal washing, skin washing

The parents of a 2-year-old boy bring him into the physician’s office in December for the complaint of cold symptoms for 4 days. The nurse notices that the child does not have shoes or socks on. The parents are upset when the physician orders a social services consult. What is the rationale for the consult?

a. the parents waited 4 days to bring the child into the office

b. the child does not have shoes or socks on in December

c. the parents are upset with the physician

d. the child has a viral illness

The rationale for the consult is that the child b. does not have shoes or socks on in December. Dressing a child inappropriately, especially during cold weather, is a type of physical neglect. It is a more subtle type of abuse than physical abuse, but it can be just as damaging to a child.

A 6-month-old infant is brought to the emergency room. The parents report that he “just won’t wake up”. Upon physical exam, the only other sign besides the level of consciousness is the presence of retinal hemorrhages. The nurse would suspect what has occurred?

a. the infant has been dropped

b. the infant has ingested a medication

c. the infant has been shaken

d. the infant has meningitis

The nurse would suggest that c. the infant has been shaken. Violent shaking of a small infant can result in whiplash to the neck, edema of the brainstem, and retinal hemorrhages. This is referred to as “shaken baby syndrome”. The damage inflicted is not readily apparent.

Which situation would lead the nurse to suspect that a child has been maltreated?

a. the 6-month-old infant with a fractured femur

b. the 7-year-old girl who had a near-drowning experience

c. the 14-year-old boy who overdosed on acetaminophen

d. the 18-month-old toddler with a concussion

The a. 6-month-old infant with a fractured femur would lead the nurse to suspect that a child has been maltreated. Infants are not usually able to accidentally cause an injury to the femur bone.