Learning Objectives

• Identify suspicious signs of child abuse, domestic violence, and elder abuse.
• Discuss common traits of victims of any type of abuse.
• Discuss common traits of abusers.
• Identify common nurses' reactions to abuse.

Glossary

Abuse – Willful infliction of physical injury or mental anguish or the deprivation by the caregiver of essential services.

Domestic (intimate partner, spouse abuse) violence – Intentionally inflicting or threatening physical injury or cruelty to one's partner.

Economic abuse (fiduciary) – Using another's resources for one's own personal gain without permission or making the victim financially dependent on the abuser.

Family violence – At least one family member is using physical or sexual force against another that leads to physical or emotional injury.

Incest– Any type of exploitive sexual experience between relatives or surrogate relatives before a victim reaches 18 years of age.

Neglect– Deliberate deprivation of necessary and available resources, such as medical or dental care.

Physical abuse– Deliberate violent actions that inflict pain or nonaccidental injury.

Psychological (emotional) abuse– Deliberate and willful destruction or significant impairment of a person's sense of competence by battering the victim's self-esteem and inhibiting normal psychosocial development.

Sexual abuse– Using the victim for sexual gratification when the victim is unable to resist or consent. This includes rape and developmentally inappropriate sexual contact, incest, and using a child for prostitution or pornography.

Shaken-baby syndrome– When an infant is violently shaken by the extremities or shoulders, usually out of frustration and rage over the child's incessant crying.

Family violence may be America's number one public health issue, yet many nurses caring for victims of this type of violence are often unaware that it is occurring within the families of their patients. Child abuse, domestic violence (also called intimate partner abuse), and elder abuse can lead to life-long emotional and physical problems for the victims and tears away at the very fabric of society as a whole. Carson & Smith-DiJulio (2006) note that 50% of all Americans have experienced violence in their family. It occurs in all segments of society. Family violence is often part of the history of violent criminals and runaways.

Victims are often too fearful or ashamed to report abuse, become adept at hiding the signs, or use massive denial to convince themselves that the abuse is not that bad, so that a violent family situation often goes unnoticed by outsiders. Health-care professionals must be vigilant to recognize the overt and covert signs of abuse. Every state mandates that suspected child abuse be reported, and some states are enacting similar laws for domestic violence and elder abuse. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now also requires that standards for identifying and providing services to victims of child abuse, domestic violence, and elder abuse be in place (2001). Nurses in all settings must be alert to signs of abuse. Home health nurses in particular are in a key role to identify abuse within a patient's family.

Child abuse includes physical and emotional abuse, neglect, and sexual abuse, and occurs at all socioeconomic levels. Although statistics are difficult to attain, it is estimated that at least 1 million American children are victims of abuse and neglect each year (2006 Center for Disease Control and Prevention). The youngest children (less than 4 years of age) are the most vulnerable and the most likely to die from abuse or neglect. Reported cases of child abuse have steadily increased over the last few years, but many cases are not reported. Children are a most vulnerable segment of the population because they depend on others for all their needs. Parents are the most common abusers. Shaken baby syndrome is a form of child abuse that contributes to infant deaths each year (Center for Disease Control and Prevention, 2006).

Many states have passed laws for safe surrender sites of newborns if a mother is unable to keep her child. Rather than abandoning an infant, mothers can leave the infant at community locations that often include hospitals and fire stations. Many at-risk teenagers who might be pregnant are often not aware of this law, so community education that reaches teens in their communities must be provided to prevent abandonment and often death of these infants.

Victims of child abuse are at an increased risk of becoming abusers as adults. Even though the child may hate the abusive situation, he or she never gets an opportunity to observe healthy parenting or to learn adaptive coping mechanisms to deal with frustration without violence. Other long-term effects include low self-esteem, high risk for substance abuse, tendency toward depression, difficulty trusting in close relationships, and violent lifestyle including crime. An early sign of child abuse in the victim can be abuse of family pets by the child. Children may try to deal with the situation by controlling another being or seeking an outlet for their anger through a more vulnerable victim. Incarcerated youths are frequently victims of child abuse and neglect (National Council on Child Abuse and Family Violence, 2004).

Girls are the most frequent victims of sexual abuse. Eighty percent of sexually abused children know their abuser, and about 50% of cases involve a parent or caregiver (Mulryan, Cathers, & Fagin, 2000). Long-term effects of sexual abuse include fear of intimacy, sexual problems, eating disorders, and an overwhelming sense of powerlessness. Victims may block out the memory of these incidents until later in life, when a major event or trauma triggers memory recall. Exploiting children in pornography has been increasing with access to the Internet.

Domestic violence most often refers to men abusing their female partners. However, women abusing their male partners or abuse within homosexual couples does occur. This is an enormous societal problem. Like child abuse, domestic violence is found at all socioeconomic levels. It accounts for 22% to 35% of emergency department visits for women (Shea, Mahoney, & Lacey, 1997). Victims of abuse may endure physical, emotional, and sexual abuse. The abuse may increase when the woman becomes pregnant if the abuser perceives competition from the baby. The battered woman syndrome refers to the common personality characteristics of these victims. These women are often economically dependent on their spouse or partner, exhibit very low self-esteem, and believe that they somehow deserve the abuse. Pediatricians may be the first to identify this victim because the woman often will not seek medical attention for herself but will seek it for her children. In addition, many times when there is domestic violence in the home, the children are victims of abuse or neglect. The National Council on Child Abuse and Family Violence in 2006 reports that women are more likely than men to be killed by someone they know and one third of female homicide victims are killed by their intimate partner (as compared with only 4% of men). The victim of the abuse may also be the killer in retaliation for past abuse.

One of the most frequently misunderstood factors in domestic violence is why these women remain with the abusers. It is important to understand that they often feel trapped and have little money, resources, or support, and fear being killed or losing custody of or potential injury to their children. Permeating all these factors is the overwhelming sense of powerlessness.

Elder abuse includes neglect as well as physical, sexual, and emotional abuse. Exploitation of the person's financial reserves by family, hired help, or strangers is also considered abuse. This can occur in the home or in residential facilities. Gray-Vickrey (2000) notes that elder abuse affects 10% of the geriatric population. This problem is greatly underreported and will continue to increase as the population grows older. One problem in reporting it is the inconsistency of laws defining elder abuse. Some states do not include neglect or psychological abuse in their definition, so it is essential to be aware of how elder abuse is defined in the state where you are working or reside. Because the abuser is often the victim's caregiver, even including the elderly spouse, victims rarely report the abuse. They fear reprisals or abandonment because they are dependent on the caregiver. Society's lack of interest in elderly people may add to the underreporting. Caring for a loved one with a cognitive impairment increases a caregiver's risk for engaging in abusive behaviors (VandeWeerd, Paveza, & Fulmer, 2005). Elder abuse can also be difficult to detect by professionals because common signs such as bruising and skin tears may be common in older populations. The patient with dementia is particularly vulnerable because he or she is unable to speak up or will not be believed because of his or her intermittent confusion.

There are similarities in all types of family violence (Table 17-1 Characteristics of Victims). A family history of abuse remains a common thread, particularly in child abuse and domestic violence. Childhood exposure to abuse increases a general sense of low self-esteem and reduced ability to deal with frustration, as well as lack of role models to learn to interact in a healthy relationship. Another similarity is the presence of a vulnerable victim.

Various theories examine what causes a person to abuse another.

Psychological theory suggests that abuse provides the abuser with a sense of power and prestige that boosts his or her self-image. The abuser hates the vulnerable powerless feelings within himself or herself and is able to block them out by creating (transferring) these denigrated feelings in others.

Sociocultural views examine the role of violence in our society. With easy access to weapons and the frequent exposure to violence from the media, potential abusers can identify violence as a socially acceptable coping mechanism. Another contributing factor is that abusers are often isolated with limited resources for assistance. Alcohol and substance abuse by the abuser also contributes by lowering impulses and inhibitions and reducing sensitivity to the impact of their behavior.

Additional traits that contribute to child abuse include a parent who sees himself or herself in the child, the child not meeting parent's expectations, and the parent's viewing the child as being there to satisfy the parent's needs. At times, a parent has no tolerance for normal child behaviors, such as crying, because of the past experience of being unable to express these needs in childhood. So the child's normal behavior reminds the parent of his or her own unmet childhood needs and unresolved anger toward his or her own parents. There is also a very high correlation with drug and alcohol abuse in this parent. The other parent is usually aware of the abuse but remains unable or unwilling to intervene. That parent may unconsciously deny the existence of abuse and is often a victim of spousal abuse. Stepparents may also be abusers as hostility toward the new mate or previous spouse is projected on the child. Incest in the family may be related to sexual problems between husband and wife. Long-term effects for child abuse victims include low self-esteem, difficulty trusting others, anxiety, anger, phobias, depression, and eating disorders.

Domestic violence tends to escalate when the abuser is intoxicated. He or she often displays tremendous jealousy and fears losing the partner. At the same time, the abuser may blame the partner for his or her own problems. Inflicting injury on the woman gives the male abuser a temporary sense of power and esteem. Other factors contributing to domestic violence include the victim's lack of financial support, belief that the children need both parents, and lack of a social support system.

As noted earlier, elder abusers are often caregivers. These abusers often have limited coping mechanisms and limited support, and are emotionally and financially dependent on the elderly person. Most often, they live with the elderly victim. At times, family members can become abusers as resentment toward the elder's dependency increases, or as retribution for the elder's perceived earlier failures as a parent.

Walker (1979) identified the cycle theory of family violence. This theory includes the following stages:

1. Tension building stage:Minor incidents of pushing, shoving, and verbal abuse occur.
2. Acute battering stage:Built-up tension is released by the abuser on the victim, leading to more brutal and uncontrollable abuse. Afterward, the abuser often does not remember the intensity of the incident. The victim is often able to remember the incident in detail without the emotion.
3. Honeymoon stage:The abuser has a sense of remorse that leads to a period of apology, and attempts to make up for the abuse by presents, special treats, and affection. The victim is finally receiving the love and attention she or he so wants and desperately desires to believe there will be no further abuse. This may allow the victim to forgive the abuser and even drop legal proceedings or plans to report the abuse. Unfortunately, this stage is usually short lived and, without intervention, becomes even briefer over time. The intensity and frequency of the cycle and severity of injuries tend to increase over time.

Related Clinical Concerns

Neurological impairment and substance abuse can trigger the abuse cycle by disinhibiting impulse control in the abuser. Illness may be a risk factor to becoming a victim. Resentments may build from caregiving responsibilities when the potential victim is dependent on the potential abuser. In addition, more violence may be inflicted on the developmentally challenged child.
Early dementia may go undiagnosed by the primary care provider unless adequate screening is done, along with communication from family who may be seeing the early signs (Cotter, 2005).

Possible Nurses' Reactions

• The most common reaction is anger and disgust directed at the abuser. These strong negative feelings can cloud the nurse's assessment and judgment, and interfere with selecting appropriate interventions for the abuser.
• The nurse may feel great sympathy for the victim.
• The nurse may also feel anger toward the battered woman who displays powerlessness. May blame her for staying with the abuser or being helpless and become angry if she does not take advice offered.
• The nurse may feel overwhelmed with the family's problems and helpless to change them, especially if the possible victim denies abuse.
• The nurse may feel intense sadness and distress, which could lead to the wish to save or “rescue” the victim. The nurse may act out these feelings by making promises to the victim that in reality cannot be met or could create an unsafe situation for both of them. This could isolate the victim even more.
• Because abuse may be so upsetting, the nurse may deny evidence or refuse to believe it, especially sexual abuse.
• The nurse may fear reporting abuse because of fear of getting involved, possible legal implications, or reprisals from abusers. The nurse may not want to be responsible for displacing the victim from the family. (Note: most states have Good Samaritan clauses in abuse laws that protect healthcare professionals from liability in reporting.)
• Abuser may intimidate the nurse.
• The nurse may identify with the victim or abuser if he or she has had personal experience with abuse.
• May participate in a conspiracy of silence with others to avoid addressing potential problems.

Assessment of Child Abuse (See Box 17-1 General Warning Signs of Abuse for General Warning Signs of Abuse)

Child Behaviors and Symptoms

• History of injury inconsistent with child's developmental level (for example, baby turning on hot water)
• Failure to thrive; dull or inactive demeanor
• Signs of malnutrition, poor hygiene, or lack of health care
• Fears discussing how injuries occurred
• Lack of reaction to frightening events (for example, being given an injection) as child has learned to hide fear
• Unusual injuries such as cigarette burns, rope burns, spiral fractures from twisting injury, bite marks
• Unexplained retinal hemorrhage, subdural hematoma—can be a sign of “shaken baby syndrome”
• May demonstrate magical thinking that doctor or nurse will know family secret
• Fear of returning home
• Apprehension when hearing a child cry because he or she thinks another child is being hurt
• Antisocial behavior, such as lying and stealing
• Wearing inappropriate clothing that covers bruises
• Bruises or bleeding in external genitalia
• Torn, bloody underclothing
• Pain on urination or frequent urinary tract infections
• Abnormal discharge or odor in genital area, indications of sexually transmitted diseases
• Pregnancy in adolescent
• Sudden onset of sexually related behavior, such as excessive masturbation, age-inappropriate sex play, or overseductive behavior
• Child being given a variety of gifts or privileges
• Change in behavior including depression, anxiety, regression, running away from home, substance abuse, decline in school performance, inflicting abuse on family pets or other animals

Parental/Abuser Behaviors

• Exaggerated or absent reaction to child's injury
• Failure to show empathy for child
• Inconsistent explanations of injuries
• Care sought for child's minor complaints but not for more obvious illness
• Demands to take child home if pressured for answers or refuses hospitalization
• Explanations not matching injuries; attempts to blame the child
• Nonabusing parent refusing to acknowledge even obvious abuse

Assessment of Domestic Violence

Victim

• Injuries to head, abdomen, breasts, genitalia
• Injuries while pregnant
• Patterns left by item used to cause injury such as rope or teeth
• Frequent urinary tract infections
• Mother of abused child
• History of rape
• Lack of care for own chronic illness
• Demonstrates guilt for seeking treatment
• Use of alcohol or tranquilizers to cover hurt
• Indicates acceptance of violence as a way to maintain family
• Socially isolated with limited financial resources and family support
• Implies a sense of deserving abuse
• Stress-related complaints of headaches, insomnia, nervousness
• Wearing clothes and makeup to cover bruises
• Denies abuse or gives explanations that do not match injury

Abuser

• Minimizes injuries even when they become life-threatening
• Speaks for victim or does not let him or her speak
• Controlling, angry
• Does not want victim to be alone with healthcare providers
• Tends to isolate victim by eliminating his or her social support system
• Insists on taking patient back home even if inappropriate
• Criticizes or humiliates victim in front of others
• Access to guns, other weapons
• Abuses family pets
• Rationalizes actions (“she deserved it”)

Assessment of Elder Abuse

Victim

• Evidence of malnutrition, dehydration, poor hygiene, pressure ulcers, not receiving needed medical care
• Unusual injuries such as twisting fractures, cigarette burns on face or back, perforated eardrums from being slapped
• Evidence of sexually transmitted diseases, unusual genital injuries
• Deterioration in mental status including confusion and depression
• Sudden lack of funds in person who previously had resources
• Frail, dependent, possible mental impairment requiring care from family member or hired help
• Extreme dependency, attachment to new caregiver
• Evidence of inappropriate use of restraints

Abuser

• Often lives with victim, lacks resources to live elsewhere
• Refusal to allow diagnostic tests, hospitalization
• Much younger than patient
• Cashes victim's social security or pension checks
• Sudden, intense involvement with patient with little input from other family members
• Evidence of drug or alcohol abuse or mental illness
• Expects dependent elder to meet his or her needs
• Caregiver overwhelmed with patient's care needs, demonstrates frustration and resentment, isolated with limited assistance
• Elderly spouse with dementia
• Coerces senior to change will to his or her benefit
• Shows no guilt or rationalizes actions

Collaborative Management

Psychotherapy

Individual and group psychotherapy are often used to treat both victims and abusers. For the victim, individual therapy may focus on the damage done to self-esteem and facing and resolving intense emotions toward the abuser, as well as toward others who may have tolerated the abuse (often the other parent in child abuse). The victim should be removed from living with the abuser before entering treatment to reduce the fear of retaliation. In domestic violence, therapists often recommend that the couple separate for a period of time before starting treatment.

Children who are suspected victims of sexual abuse need to be evaluated by therapy professionals in this specialty. Repressed, traumatic events of the past, such as childhood sexual abuse, may also be uncovered during therapy as an adult. This repressed abuse could be influencing the patient's current life without his or her knowledge. However, this is very controversial because repressed memories have been found to be inaccurate. Group therapy may also allow the victim to learn from other victims and develop assertive skills.

More intensive psychotherapy or psychiatric treatment may be required for the abuser if psychopathology is suspected.

Because family violence is a symptom of family dysfunction, family therapy is often part of the overall treatment plan. When children are in the home where abuse has occurred, they must be part of the healing process. In addition, support group programs are available for both victims and abusers.

Family Coping: Disabling evidenced by child abuse

FAMILY COPING: DISABLING evidenced by child abuse related to history of abuse in the family, lack of resources, isolation.

Child Outcomes

• Remains free from injury or neglect
• Seeks comfort and assistance from nurse

Parent Outcomes

• Seeks assistance for abusive behavior
• Demonstrates nurturing behavior toward child
• Refrains from abusive behavior

Interventions

• Establish a trusting relationship with child and parents. Avoid threatening behavior or criticizing parents in front of child. See Table 17-2 Interviewing an Abuser or Abuse Victim, Interviewing an Abuser or Abuse Victim.
• Observe parent-child interaction closely, especially when both are under stress. Observe caring and feeding behavior. In the home, observe sleeping arrangements and environmental conditions.
• Recognize that the child very often will not betray his or her parents. Even in the worst situations, the child may fear losing the only security he or she knows and consequently, will deny any problems.
• Involve the child in treatment plan to increase his or her sense of control.
• Demonstrate support, acceptance, and affection of the child. Reinforce child's self-esteem by positive feedback and recognition.
• If child needs discipline, discuss punishment, and clarify that no physical abuse will be used. Consider referral for psychiatric or play therapy evaluation to better understand what is being expressed.
• Encourage play. Be aware that child may be better able to express feelings through play.
• Reinforce parent's strengths, and acknowledge importance of continuing medical care for the child.
• Reinforce positive parenting behavior. Role-model care giving behaviors for them.
• Avoid hostility toward the parents. At the same time, maintain the child's safety. If child is at risk for being taken inappropriately by parents, have staff remain in attendance with security nearby and inform the parents of your reasons for doing so.
• If sexual abuse is suspected, child needs to be evaluated by appropriate professionals, including psychologist, pediatrician, gynecologist.
• Be aware of agency policy and state laws on reporting suspected child abuse. Contact supervisor and/or social worker to implement appropriate reporting. Participate in collecting evidence, as indicated, and ensure that proper procedures are followed.
• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

Family Coping: Disabling evidenced by domestic violence

FAMILY COPING: DISABLING evidenced by domestic violence related to vulnerable victim, abuser with family history of abuse, isolated, limited resources, and/or intense jealousy.

Victim Outcomes

• Acknowledges the abuse
• Identifies options to escape abuser
• Remains in treatment even if pressured to not obtain care

Abuser Outcomes

• Seeks assistance for abusive behavior
• Refrains from harming others

Interventions

• Establish a trusting relationship with the victim. Avoid displaying shock or disgust at the story. Encourage victim to share fears and concerns. Ask specific questions to avoid a vague response.
• Assess the victim's safety. If there is a risk, implement agency security policies, as appropriate. If victim is in the hospital, restrict phone calls and visitors. Consider a pseudonym for the patient's name. For patients at home, determine need to involve the police and information on legal restraining orders. If there are children in the home, determine their risk of injury. Be aware of state and agency policies for reporting domestic violence.
• Reinforce victim's self-esteem. Identify positive traits and coping mechanisms. Encourage victim to talk about accomplishments and goals.
• Encourage victim's participation in treatment plan including follow-up with medical appointments. Help victim take control of some areas of his or her life and make some decisions.
• If possible, identify available support systems and determine their awareness of family's problems. Encourage patient to involve some people who can help. Support maintaining regular social contacts.
• Encourage realistic evaluation situation. Do not reinforce denial or avoidance.
• Be aware that during the “honeymoon stage” the victim may not be willing to discuss abuse. Describe the cycle of abuse to the victim. Give the victim written information on resources to use at another time.
• Encourage problem solving. Challenge him or her to identify realistic options, and reinforce all efforts to be assertive.
• Encourage talking about events that led up to the abusive event. Dispel any myths of guilt or responsibility for causing or deserving the abuse.
• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

Family Coping: Disabling evidenced by elder abuse

FAMILY COPING: DISABLING evidenced by elder abuse related to multiple stressors associated with elder care.

Elder Outcomes

• Identifies resources available for assistance
• Remains safe and without injury
• Continues to receive adequate health care

Caregiver Outcomes

• Identifies resources available for assistance in patient care
• Demonstrates more effective coping mechanisms
• Provides safe care to the elderly patient

Interventions

• Assess the elderly patient's condition and determine the role of caregiver in providing adequate care. Patients with pressure ulcers, dehydration, lacerations, and bruises need to be evaluated; however, be aware that these may occur unrelated to abuse or neglect.
• If abuse is suspected, talk with patient and caregiver separately. With the patient, listen to his or her description of the caregiver and any complaints he or she may have. Then verify the information, if possible, with the caregiver, other family members, or health-care providers. Establish a trusting relationship with the caregiver by acknowledging positive accomplishments, as well as the stress of caregiving.
• If signs of abuse occur in a long-term care facility, observe patient care routines and the care of other patients. Note the use of restraints and the quality of hygiene provided. In the home, if patient is being left alone while restrained, action must be taken immediately to stop this unsafe practice.
• Provide education to staff in long-term care on identifying and preventing abuse or neglect.
• Recognize that patients with altered mental status may falsely accuse caregivers of abuse. However, every accusation must be evaluated.
• Encourage the patient to be as independent as possible by remaining involved with family and friends, having his or her own telephone, and having neighbors check his or her status regularly. Appropriate independence will also promote self-esteem and self-reliance. Even in the highly dependent patient, it is important to maintain the individual's sense of control.
• Encourage problem-solving skills in patient and caregiver. Promote their abilities to find alternate solutions under stress.
• If patient is in an unsafe environment, implement agency policies and state laws as appropriate to determine reporting mechanism and action. If patient refuses to leave environment, determine patient's ability to make decisions. Involve physician and/or social worker as needed. Consider psychiatric evaluation. Involve family and friends if needed to encourage patient action.
• Determine caregiver's stress level and determine if additional resources are available and would defuse the situation.
• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

Alternate Nursing Diagnoses

• Caregiver Role Strain
• Family Processes, Interrupted
• Knowledge, Deficient
• Noncompliance
• Parenting, Impaired
• Post-Trauma Response
• Powerlessness
• Rape-Trauma Syndrome
• Violence, Risk for

Patient & Family Education

• Teach effective parenting skills, including appropriate discipline. Abusive parents need skills in disciplining children without violence and often need to learn acceptable outlets for their frustration.
• Incorporate assertive skills to teach potential victims, including young children, to speak up when rights are violated and learn to say no.
• Teach family members the signs of abuse and how to report it.
• Family members need guidelines for hiring caregivers and selecting assisted living situation.
• Teach older adults how to avoid abusive situations by maintaining active social network, and to seek legal advice before allowing anyone to take their possessions or manage their finances. The American Association of Retired Persons has written guidelines to avoid elder abuse. These can be accessed through the Web site www.aarp.org.
• Teach a victim of domestic violence to identify a plan in advance to leave home when needed. This plan should include having a place to go, setting aside money, and implementing security measures for victim and children.
• When children must be removed from their home, prepare them for the emotional grief response that may occur when they are separated from their parents. No matter how bad the home was, children will still grieve. Be sure they understand that they are not being punished.
• Suspected abusers need information on alternative ways to resolve conflicts. If appropriate, refer them to counselors who specialize in abuse and can educate them on the role of substance abuse and violence.
• Review with victims and abusers the need to involve family and friends for assistance.
• Ensure pregnant and at-risk teens know about safe surrender sites in the community where newborns could be safely dropped off if decision made not to keep the infant. (National Crime Prevention Council website can give more information at ncpc.org.)

• If abuse is suspected, carefully document, possibly with photos, any evidence of wounds, injuries, or poor hygiene. Follow institutional protocols carefully if called upon to participate in evidence collection.
• Document the nature of interactions between victim and abuser.
• Note victim's reaction to the abuser, especially when discharging patient.
• Document victim's report of abuse.
• Document interventions made, including reporting abuse and maintaining patient safety.
• Document any discrepancies between the victim and potential abuser's explanation of injuries.

When to Call for Help

• Aggressive, belligerent behavior escalates to violence.
• Presence of abuser leads patient to fear of violence or of being kidnapped.
• Abuser is intoxicated.
• Abuser intimidates patient or staff.
• Victim leaves healthcare agency to return to unsafe environment

Who to Call for Help

• Social Worker
• Protective Service agencies
• Security/law enforcement

Community-Based Care

• Provide written information on appropriate resources, including parenting support groups such as Parents Anonymous; parenting education programs; shelters; safe houses; 24-hour local crisis hot lines for abuse or National Child Abuse Hotline (1-800-4ACHILD); and National Organization for Victim Assistance (800-TRY-NOVA). If abuse is suspected and patient denies it, provide the information, and encourage patient to keep it in a safe place. For elder abuse, contact the local Adult Protective Services. Many Web sites are available for assistance including National Clearinghouse on Child Abuse and Neglect (www.ncadv.org), National Council on Child Abuse and Family Violence (www.nccafv.org).
• Additional Web sites include www.preventchildabuse.org and www.acf.dhhs.gov/programs/cb/
• Provide information on legal referrals and security measures. If police are involved, reinforce information they give to patient.
• If victim is staying in abusive situation because of fear of leaving family pet, give information on local humane societies that can help with animal care if the victim leaves the home. Veternarians may become aware of abuse when a family pet is injured.
• As appropriate, refer patient for counseling or family therapy.
• Refer for home health follow-up to assess home environment. Inform all referring agencies of concerns about abuse.
• Vocational counseling information may be helpful to the domestic violence victim.
• Anticipate caregiver needs in the home and provide adequate support and equipment.
• Discuss day-care options for children or elderly people.