1. DOMESTIC VIOLENCE^*:
1. Characteristics:
1. Victims: feel helpless, powerless to prevent assault; blame themselves; ambivalent about leaving the relationship.
2. Abusers: often blame the victims; have poor impulse control; use power (physical strength or weapon) to threaten and subject victims to their assault.
3. Cycle of stages, with increase in severity of the battering:
1. Buildup of tension (through verbal abuse): abuser is often drinking or taking other drugs; victim blames self.
2. Physical abuse: abuser does not remember brutal beating; victim is in shock and detached ("honeymoon" phase).
3. Calm: abuser "makes up," apologizes, and promises "never again"; victim believes and forgives the abuser, and feels loved.
2. Risk factors:
1. Learned responses: abuser and victim have had past experience with violence in family; victim has "learned helplessness."
2. Women who are pregnant and those with one or more preschool children, who see no alternative to staying in the battering relationship.
3. Women who fear punishment from the abuser.
3. Assessment:
1. Injury to parts of body, especially face, head, genitals (e.g., welts, bruises, fracture of nose).
2. Presents in the emergency department with report of "accidental injury."
3. Severe anxiety.
4. Depression.
4. Analysis/nursing diagnosis:
1. Risk for injury related to physical harm.
2. Posttraumatic response related to assault.
3. Fear related to threat of death or change in health status.
4. Pain related to physical and psychological harm.
5. Powerlessness related to interpersonal interaction.
6. Ineffective individual coping related to situational crisis.
7. Spiritual distress related to intense suffering and challenged value system.
5. Nursing care plan/implementation:
1. Provide safe environment; refer to community resources for shelter.
2. Treat physical injuries.
3. Document injuries.
4. Supportive, nonjudgmental approach: identify woman's strengths; help her to accept that she cannot control the abuser; encourage description of home situation; help her to see choices.
5. Encourage individual and family therapy for victim and abuser.
6. Evaluation/outcome criteria:
1. Physical symptoms have been treated.
2. Discusses plans for safety (for self and any children) to protect against further injury.
2. RAPE-TRAUMA SYNDROME:
1. Definition: forcible perpetration of an act of sexual intercourse on the body of an unwilling person.
2. Assessment:
1. Signs of physical trauma—physical findings of entry.
2. Symptoms of physical trauma—verbatim statements regarding type of sexual attack.
3. Signs of emotional trauma—tears, hyperventilation, extreme anxiety, withdrawal, self-blame, anger, embarrassment, fears, sleeping and eating disturbances, desire for revenge.
4. Symptoms of emotional trauma—statements regarding method of force used and threats made.
3. Analysis/nursing diagnosis: rape-trauma syndrome related to phases of response to rape:
1. Acute response: volatility, disorganization, disbelief, shock, incoherence, agitated motor activity, nightmares, guilt (feels that should have been able to protect self), phobias (crowds, being alone, sex).
2. Outward coping: denial and suppression of anxiety and fear (silent rape syndrome), feelings appear controlled.
3. Integration and resolution: confronts anger with attacker; realistic perspective.
4. Nursing care plan/implementation in counseling victims of rape. Figure 10-8. Victim Decisions Following a Sexual Assaultis a summary of self-care decisions a victim faces the first night following a sexual assault.
1. Overall goals:
1. Protect legal (forensic) evidence.
2. Acknowledge feelings.
3. Face feelings.
4. Resolve feelings.
5. Maintain and restore self-respect, dignity, integrity, and self-determination.
2. Work through issues:
1. Handle legal matters and police contacts.
2. Clarify facts.
3. Assist medical examiner in collecting DNA evidence.
4. Get medical attention if needed.
5. Notify family and friends.
6. Understand emotional reaction.
7. Attend to practical concerns.
8. Evaluate need for psychiatric consultations.
3. Acute phase:
1. Decrease victim's stress, anxiety, fear.
2. Seek medical care.
3. Increase self-confidence and self-esteem.
4. Identify and accept feelings and needs (to be in control, cared about, to achieve).
5. Reorient perceptions, feelings, and statements about self.
6. Help resume normal lifestyle.
4. Outward coping phase:
1. Remain available and supportive.
2. Reflect words, feelings, and thoughts.
3. Explore real problems.
4. Explore alternatives regarding contraception, legal issues.
5. Evaluate response of family and friends to victim and rape.
5. Integration and resolution phase:
1. Assist exploration of feelings (anger) regarding attacker.
2. Explore feelings (guilt and shame) regarding self.
3. Assist in making own decisions regarding health care.
6. Maintain confidentiality and neutrality—facilitate person's own decision.
7. Search for alternatives to giving advice.
8. Health teaching:
1. Explain procedures and services to victim.
2. Counsel to avoid isolated areas and being helpful to strangers.
3. Counsel where and how to resist attack (scream, run unless assailant has weapon).
4. Teach what to do if pregnancy or STI is outcome.
5. Evaluation/outcome criteria: little or no evidence of possible long-term effects of rape (guilt, shame, phobias, denial).
3. CHILD WHO IS VICTIM OF VIOLENCE:
1. Assessment—clues to the identification of a child who is a victim of violence.^*
1. Clues in the history:
1. Significant delay in seeking medical care.
2. Major discrepancies in the history:
1. Discrepancy between different people's versions of the story.
2. Discrepancy between the history and the observed injuries.
3. Discrepancy between the history and the child's developmental capabilities.
3. History of multiple emergency department visits for various injuries.
4. A story that is vague and contradictory.
2. Clues in the physical examination:
1. Child who seems withdrawn, apathetic, and does not cry despite the injuries.
2. Child who does not turn to parents for comfort; or unusual desire to please parent; unusual fear of parent(s).
3. Child who is poorly nourished and poorly cared for.
4. The presence of bruises: multiple bruises, welts, and abrasions, especially around the trunk and buttocks; lesions resembling bites or fingernail marks; old bruises in addition to fresh ones (Table 10.14. Estimation of Time at Which Soft Tissue Injury Occurred).
5. The presence of suspicious burns:
1. Cigarette burns.
2. Scalds without splash marks or involving the buttocks, hands, or feet but sparing skinfolds.
3. Rope marks.
6. Clues in parent behavior—exaggerate care and concern.
7. X-rays: old fractures or dislocation, especially in child under 3 years.
2. Analysis/nursing diagnosis:
1. Same as for domestic violence (see Selected Specific Crisis Situations: Problems Related to Abuse/Violence).
2. Altered parenting related to poor role model/identity, unrealistic expectations, presence of stressors and lack of support.
3. Low self-esteem related to deprivation and negative feedback.
3. Nursing care plan/implementation:
1. Same as for domestic violence.
2. Report suspected child abuse to appropriate source.
3. Conduct assessment interview in private, with child and parent separated.
4. Be supportive and nonjudgmental.
4. Evaluation/outcome criteria:
1. Same as domestic violence.
2. Child safety has been ensured.
3. Parent(s) or caregivers have agreed to seek help.
4. SEXUAL ABUSE OF CHILDREN:
1. Assessment—characteristic behaviors:
1. Relationship of offender to victim: many filling paternal role (uncle, grandfather, cousin) with repeated, unquestioned access to the child.
2. Methods of pressuring victim into sexual activity: offering material goods, misrepresenting moral standards ("it's OK"), exploiting need for human contact and warmth.
3. Method of pressuring victim to secrecy (to conceal the act) is inducing fear of punishment, not being believed, rejection, being blamed for the activity, abandonment.
4. Disclosure of sexual activity via:
1. Direct visual or verbal confrontation and observation by others.
2. Verbalization of act by victim.
3. Visible clues: excess money and candy, new clothes, pictures, notes; enlarged vaginal or rectal orifice; stains and/or blood on underwear.
4. Signs and symptoms: bedwetting, excessive bathing, tears, avoiding school, somatic distress ( GI and urinary tract pains). Genital irritation (itching, bruised, bleeding, pain); unusual sexual behavior.
5. Overly solicitous parental attitude toward child.
2. Analysis/nursing diagnosis:
1. Altered protection related to inflicted pain.
2. Risk for injury related to neglect, abuse.
3. Personal identity disturbance related to abuse as child and feeling guilty and responsible for being a victim.
4. Ineffective individual coping related to high stress level.
5. Sleep pattern disturbance related to traumatic sexual experiences.
6. Ineffective family coping.
7. Altered family processes related to use of violence.
8. Altered parenting related to violence.
9. Powerlessness related to feelings of being dependent on abuser.
10. Social isolation/withdrawal related to shame about family violence.
11. Risk for altered abuse response patterns.
3. Nursing care plan/implementation:
1. Establish safe environment and the termination of trauma.
2. Encourage child to verbalize feelings about incident to dispel tension built up by secrecy.
3. Ask child to draw a picture or use dolls and toys to show what happened.
4. Observe for symptoms over a period of time.
1. Phobic reactions when seeing or hearing offender's name.
2. Sleep pattern changes, recurrent dreams, nightmares.
5. Look for silent reaction to being an accessory to sex (i.e., child keeping burden of the secret activity within self); help deal with unresolved issues.
6. Establish therapeutic alliance with parent who is abusive.
7. Health teaching:
1. Teach child that his or her body is private and to inform a responsible adult when someone violates privacy without consent.
2. Teach adults in family to respond to victim with sensitivity, support, and concern.
4. Evaluation/outcome criteria:
1. Child's needs for affection, attention, personal recognition, or love met without sexual exploitation.
2. Perpetrator accepts therapy.
3. Conspiracy of silence is broken.
5. Summary: signs that are common to both physical and sexual abuse:
1. Parental behaviors:
1. Blaming child or sibling for injury.
2. Anger (rather than providing comfort) toward child for injury.
3. Hostility toward health-care providers.
4. Exaggeration or absence of response from parent regarding child's injury.
2. Child (toddler or preschooler):
1. No protest when parent leaves.
2. Shows preference for health-care provider over parent.
3. Signs of "failure to thrive" syndrome.
3. Other signs:
1. History: inconsistent with stages of growth and development.
2. Inconsistent details of injury between one person and another.
5. ELDER ABUSE/NEGLECT:
1. Definition: battering, psychological abuse, sexual assault, or any act or omission by personal caregiver, family, or legal guardian that results in harm or threatened harm.
2. Concepts, principles, and characteristics:
1. Elders who are currently being abused often abused their abusers—their offspring. Violence is a learned behavior.
2. Victim characteristics: diminished selfesteem, feeling responsibility for the abuse, isolated.
3. Abuser characteristics: usually has physical or psychosocial stressors related to marital or fiscal difficulties; substance abuse.
4. Legal: most states have mandatory laws to report elder abuse, although many cases are not reported because of shame, fear of more abuse, cultural/religious beliefs, optimism, loyalty, financial dependency.
5. Types of abuse:
1. Financial abuse (e.g., fraudulent monetary schemes, theft [money, property, or both]).
2. Neglect (e.g., withholding food, water, medications; no provision for assistive devices [dentures, hearing aids, glasses, canes], adequate heating).
3. Psychological abuse (e.g., verbal abuse, yelling, harsh commands, insults, threats, ignoring, social isolation, and withholding affection).
4. Physical abuse (e.g., beating, shoving, bruising, subconjunctival hemorrhage; physical restraints, rape).
3. Assessment:
1. Risk factors:

   Victim:	Abuser:
   Poor health	Substance abuse
   isolated	Stressful life events
   Impaired memory, thinking	Interpersonal problems
   ← Hx: Mental illness →
   ← Hx: Family violence →
   ← Financial difficulties →
   ← Dependency →
   ← Share living space →

2. Behavioral clues: agitation, anger, denial, fear, poor eye contact; confusion, depression, withdrawal, unbelievable stories about causes of injuries.
3. Physical indicators: weight loss; dehydration; unexplained cuts, welts, burns, bruises, puncture wounds; untreated injuries, fractures, contractures; unkempt; noncompliance with medical plan of care; severe skin breakdown.
4. Financial matters (e.g., recent changes in will; unusual banking activity; missing checks, personal belongings; forged signatures; unwillingness to spend money on the elder).
4. Analysis/nursing diagnosis:
1. Risk for injury related to neglect, abuse.
2. Fear.
3. Powerlessness related to dependency on abuser.
4. Unilateral neglect.
5. Spiritual distress.
6. Altered family processes related to use of violence.
7. Caregiver role strain.
5. Nursing care plan/implementation:
1. Primary prevention:
1. Early case-finding; early treatment.
2. Referral to community services for caregiver (e.g., respite care) before serious abuse occurs.
2. Secondary prevention:
1. Report case to law enforcement agencies.
2. Provide elder with phone number for confidential hotline.
3. Plan for safety of elder (e.g., shelter).
3. Tertiary prevention:
1. Counseling, support, and self-help groups for victim.
2. Legal action against abuser.
6. Evaluation/outcome criteria:
1. Elder develops trust in caregivers, without fear of further abuse.
2. Spiritual well-being is enhanced, with diminished feelings of guilt, hopelessness, and powerlessness.

^* Source: © Lagerquist, S: In NurseNotes Psychiatric-Mental Health. A.T.I.

^* Adapted from Caroline, N: Emergency Care in the Streets, ed 5. Little, Brown, Boston (out of print)