Reference Materials: ATI Ch. 25, Lippincott p. 255-272
Objectives
Differentiate between anger and aggression
Identify strategies to de-escalate aggression in patients with altered mental status.
Describe causes of violence
Discuss direct and indirect causes of abuse, assault, homicide, rape, and rape trauma syndrome.
Identify safety concerns
Safety concerns for patients suffering from family and community violence and therapeutic intervention strategies.
Legal and ethical issues
Explore potential legal and ethical implications in nursing management of patients affected by violence.
Risk factors and prevention
Understand risk factors and prevention methods related to abuse, assault, homicide, rape, and rape trauma syndrome.
Culturally competent care
Evaluate the nursing process for providing culturally competent care to victims of violence.
Treatment and therapies
Describe and evaluate treatments provided for victims of violence and expected outcomes, particularly in instances of rape trauma syndrome.
Sensitive Content
Trigger Warning: The content may provoke distress as it may resonate with personal experiences of violence.
Resources:
National Domestic Violence Hotline: 1-800-799-SAFE [https://www.thehotline.org/here-for-you/]
Texas Council on Family Violence: [https://tcfv.org/]
Human Trafficking Hotline: [https://humantraffickinghotline.org/en/resources]
Definition of Violence
Definition: Violence is defined as an act from one person to another; it is a social act that abuses power.
Cycle of Violence: Describes the cyclical nature of violence between partners or spouses:
Tension-Building Phase: Minor anger escalates, often including verbal abuse, threats, and minor physical incidents. The victim may attempt to appease the perpetrator, minimize the violence, and walk on eggshells to avoid further escalation.
Acute Battering Phase: The most violent phase with the shortest duration. This phase involves uncontrolled, severe violence, often triggered by a minor incident, leading to significant physical injury and psychological trauma.
Honeymoon Phase: The situation calms down; the perpetrator expresses kindness, remorse, offers apologies and gifts, or makes promises to change. The victim may accept these apologies, feel hopeful for change, and withdraw previous reports or plans to leave, reinforcing the cycle.
Psychological Dynamics: Victims may feel powerless, accept blame, and hope for change in perpetrators.
Risk Factors for Violence
Vulnerable Populations:
Female partners, pregnancy, children, older adults, and family groups exhibit increased risk factors due to potential power imbalances, dependency, or societal vulnerabilities.
Types of Violence
Physical Violence: Includes kicking, striking, strangling, hitting with objects, restraining, burning, and other acts causing bodily harm. It can result in both immediate physical injuries and long-term health and psychological issues.
Sexual Violence: Involves sexual acts without consent, including forced penetration, inappropriate touching, sexual coercion, and psychological manipulation to achieve sexual contact.
Emotional Violence: Aims to diminish the victim's feelings of self-worth through constant criticism, humiliation, control, isolation from friends and family, and threats. This type of abuse erodes self-esteem and can lead to severe mental health issues.
Neglect: Failure to provide necessary emotional, physical, medical, nutritional, educational, or other care. This can lead to serious developmental delays, health problems, and even death, especially in children and older adults.
Economic Abuse: Involves withholding funds or financial support, controlling all finances, preventing employment, sabotaging job efforts, or stealing the victim's money. This type of abuse creates financial dependency, trapping victims in abusive relationships.
Stalking: Characterized by a pattern of unwanted attention, contact, and harassment, causing fear for safety.
Human Trafficking: Involves force, fraud, or coercion for labor or sexual services.
Child Abuse and Neglect: Failure to meet basic needs of a child encompassing various dimensions (educational, health care, emotional, physical).
Abuse of Older Adults: Involves neglect of health care needs, financial abuse, and both physical and psychological abuse.
Characteristics of Vulnerable Persons and Perpetrators
Vulnerable Persons:
Low self-esteem; attempts to protect the perpetrator.
Denial of abuse severity; may appear angry or afraid.
Feelings of hopelessness and helplessness.
Perpetrators:
May employ threats and intimidation.
Exhibit poor impulse control and violent outbursts.
Frequently have histories of substance abuse or familial violence exposure during childhood.
Nursing Care Strategies
Documentation: Document subjective data (patient's exact quotes, emotional state) and objective data (physical findings, injuries observed, non-verbal cues) from patient assessments precisely and thoroughly. Ensure referrals made are also documented.
Basic Care: Treat any injuries appropriately and make referrals as necessary to social work, mental health services, or legal aid.
Safety Planning: Collaborate with patients to develop comprehensive safety strategies, including identifying triggers for violence, creating an emergency escape plan, identifying a safe place to go, developing a code word, and packing an emergency bag with essential documents and supplies. Involve support networks if appropriate.
Mandatory Reporting: As a mandatory reporter, nurses are legally obliged to report suspicions of child or vulnerable adult abuse to the appropriate authorities.
Crisis Intervention: Provide effective crisis intervention methods to resolve instances of family violence, focusing on immediate safety and emotional support.
Assessment Tools
#### Abuse Assessment Screen
Questions regarding emotional/physical abuse, sexual violations, and fear of partner implications using direct, non-judgmental language. Includes prompts for documenting injuries and providing supportive verbal affirmations.
#### Danger Assessment
Evaluates risk factors associated with potential homicide in abusive relationships using a scoring system. Key assessment questions include the frequency and severity of violence, history of strangulation, presence of weapons, threats to kill, forced sex, drug/alcohol use by partner, and overall control exerted by the partner.
Sexual Assault and Related Issues
Types of Sexual Abuse and Violence:
Sexual assault encompasses forced sexual contact (e.g., inappropriate touching, intercourse).
Includes denial of emergency contraception, organized rape during wars, and sexual homicide.
Definition of rape: non-consensual activity that includes any penetration.
Types of Rape:
Stranger rape, marital rape, date rape, acquaintance rape.
Drug-Assisted Rape: Involves substances like Gamma-hydroxybutyrate (GHB), Flunitrazepam (Rohypnol), and Ketamine.
Expected Findings with Rape Trauma Syndrome
Somatic Reactions: Initial emotional outbursts (e.g., crying, fear, anger) followed by controlled behaviors (e.g., calm, withdrawn, numb). Physical symptoms such as muscle tension, headaches, gastrointestinal upset, sleep disturbances, and a general feeling of being unwell are common.
Acute Stress Disorder: Symptoms lasting from 3 days to 1 month, including intrusive memories, negative mood, dissociative symptoms (e.g., altered sense of reality, amnesia), avoidance of stimuli related to the trauma, and hyperarousal (e.g., hypervigilance, exaggerated startle response). This indicates transition to PTSD if prolonged beyond one month.
Compound Rape Reaction: Occurrence of additional mental (e.g., pre-existing depression, anxiety, substance abuse worsening) or physical disorders (e.g., chronic pain, irritable bowel syndrome) subsequent to the assault. May present abrupt relational changes or heightened anxiety.
Silent Rape Reaction: Survivor does not report the assault; exhibits symptoms of distress without visible emotional responses or direct acknowledgment of the trauma. Symptoms may include sudden phobias, changes in lifestyle (e.g., moving, changing jobs), difficulties in relationships, increased anxiety, depression, or an unexplained increase in gynecological problems.
Nursing Care Approaches for Survivors
Conduct a self-assessment to address personal feelings and biases, ensuring empathetic and objective care.
Provide a safe, private, and calming environment for the patient, ensuring confidentiality and control over their immediate surroundings.
Treat any injuries as needed following protocols and provide preventative care for STIs and pregnancy.
Evaluate and assess existing patient support systems and integrate them into the care plan, if appropriate and with patient consent.
Encourage expression of emotions from the patient in a non-judgmental way, validating their feelings and experiences.
Sexual Assault Nurse Examiner (SANE) Role
Requirements: Licensed RN with at least 2 years of experience and certifications in both adult and pediatric examinations.
Responsibilities include conducting thorough physical examinations, ensuring patient safety, and meticulously collecting evidence following strict chain-of-custody protocols, including establishing a detailed timeline from the patient. This role also involves providing compassionate, trauma-informed care.
Ensure that the patient refrains from eating or drinking, showering, or changing clothes before the SANE arrives to preserve evidence.
Constantly reassure the patient about their safety and validate their courage in seeking help, emphasizing that they are not to blame.
Care After Discharge
Resources Provided: Offer 24/7 hotline numbers for continuous psychological support and crisis intervention. Provide information on local support groups and counseling services.
Emphasize the importance of self-care and follow-up healthcare appointments for physical health, mental health, and any legal proceedings.