Chapter 11

Abuse and Violence

Clinical Picture of Abuse and Violence
Abuse is the wrongful use
and maltreatment of
another person…
…can be
child,
spouse,
partner,
or elder
parent
Victims of abuse and trauma can have both
physical and psychological injuries,
including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or dehumanized;
low self-esteem
• Relationship problems; mistrust of authority
figures
Characteristics of Violent Families

• Social isolation
• Power and control by abusive person
• Alcohol and other drug abuse
• Intergenerational transmission process
Cultural Considerations

• Domestic violence occurs in families of

all ages and from all ethnic, racial,
religious, socioeconomic, and sexual
orientation backgrounds
• Battered immigrant women face
increased legal, social, and economic
barriers
Spouse or Partner Abuse

• Involves the mistreatment of one

person by another in the context of an
intimate relationship
• 90% to 95% of domestic violence
victims are women
• Pregnancy escalates domestic violence
• Abuse can occur in same-sex
relationships
Spouse or Partner Abuse (cont’d)
Cycle of Abuse and Violence
• Initial episode of violence
• Honeymoon period: abuser
promises it will never happen
again, gives gifts and flowers,
is affectionate
• Tensions begins to build
with arguments, silence,
complaints
• Violence occurs again
• This cycle repeats over and
over
Spouse or Partner Abuse (cont’d)
Assessment
• It is necessary to identify victims of
abuse in all settings, since they often
do not seek treatment directly
• SAFE questions can be used to assess:
– Stress/Safety
– Afraid/Abused
– Friends/Family
– Emergency plan
Spouse or Partner Abuse (cont’d)
Treatment and Intervention
• Domestic violence laws vary among states
and are not always followed
• Women may stay in abusive relationships
for fear of violence to children, fear of
increased violence or death, financial
dependence
• Identifying women in violent situations is a
priority. More health care agencies are
beginning to ask routine screening
questions of all women
Spouse or Partner Abuse (cont’d)

Treatment and Intervention (cont’d)

• Providing women with information about
shelters, services, and so forth is essential
• The nurse must never indicate that he or she
thinks the woman should leave the
relationship; need to keep the door open for
further communication
Child Abuse
Child abuse is intentional injury of a
child, including:
– Physical abuse or injuries
– Sexual assault or intrusion
– Neglect or failure to prevent harm
(failure to provide adequate physical or
emotional care or supervision;
abandonment)
– Psychological abuse
All states have mandatory child abuse
reporting laws that include nurses.
Child Abuse (cont’d)
Parents who abuse children:
• Have minimal parenting knowledge and skills
• Are emotionally immature and needy
• Are incapable of meeting their own needs, much
less those of a child
• Often raise their children the way they were
raised, including corporal punishment and abuse
• Expect the child to meet all their needs for love
and affection
Child Abuse (cont’d)
Assessment
Suspect child abuse when there are:
• Unusual injuries such as scalding and cigarette
burns
• Delays in seeking treatment, inconsistent history,
or illogical explanation for the injuries
• Urinary tract infections; red, swollen, or bruised
genitalia; tears of vagina or rectum
• Old injuries that were not treated
• Multiple, unexplained bruises
Child Abuse (cont’d)
Treatment and Intervention
• Getting the child to a safe place once
abuse is identified
• Family therapy
• Individual therapy for the child
• Intensive involvement of social service
agencies
• Treatment for parents for any
substance abuse or psychiatric issues
Elder Abuse
Elder abuse is maltreatment of older
adults by family members or
caretakers, including:
– Physical, sexual, or psychological
abuse or neglect
– Self-neglect
– Financial exploitation
– Denial of adequate medical treatment
Elder Abuse (cont’d)

• 60% of perpetrators are spouses, 20%

adult children, 20% others
• People who abuse elders are almost
always in a caretaker role
• Elders are reluctant to report abuse
because they fear the alternative
(nursing home)
• Not all states have mandatory elder
abuse reporting laws
Elder Abuse (cont’d)
Assessment
Possible indicators of physical abuse:
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical
appointments
• Untreated medical condition
Elder Abuse (cont’d)

Assessment (cont’d)
Possible indicators of emotional or
psychological abuse:
• Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation
Elder Abuse (cont’d)
Assessment (cont’d)
Possible indicators of self-neglect:
• Inability to manage own finances
• Inability to perform activities of daily
living
• Inadequate clothing
• Signs of malnutrition or dehydration
• Rashes and sores
Elder Abuse (cont’d)
Assessment (cont’d)
Possible indicators of financial exploitation:
• Inability to manage money
• Unusual activity in bank accounts
• Different signatures on checks
• Recent changes in will that client could not
make
• Missing valuables
Elder Abuse (cont’d)
Assessment (cont’d)
Possible indicators of abuse by caregiver:
• Caregiver speaks for the elderly person
• Caregiver shows indifference or anger
• Caregiver blames elderly person for
physical problems
• Caregiver shows defensiveness
• Caregiver and client give conflicting
accounts
Elder Abuse (cont’d)

Treatment and Intervention

Treatment and intervention may involve:
• Providing adequate support and respite
for the caregivers
• Changing caregiving arrangements
• Moving the elderly person to a safe
environment
Rape

Rape is a crime of violence and

aggression expressed through sexual
means. The act is against the victim’s
will or against someone who cannot
give consent.
Rape (cont’d)
• The victim can be any age
• Half of rapes are committed by
someone known to the victim
• Rape is underreported to the police
• Same-sex rape can occur between
partners but is most common in
institutions
Rape (cont’d)

Male rapists have been categorized as:

• Sexual sadists aroused by pain of
victim
• Exploitative predators
• Inadequate men
• Those who rape as a displaced
expression of anger and rage
Rape (cont’d)
Physical and psychological trauma to
rape victims is severe:
• Medical problems: victims are
significantly less healthy; pregnancy,
STDs, HIV are concerns
• Victims may feel frightened, helpless,
guilty, humiliated, and embarrassed;
may avoid previously pleasurable
activities
• Relationship problems may occur
Rape (cont’d)
Treatment and Intervention
• Immediate support to ventilate fear
and rage
• Care by persons who believe that the
rape happened
• Coordination of all needed services in
one location
Rape (cont’d)
Treatment and Intervention (cont’d)
• Giving the victim control over choices
whenever possible
• Prophylactic treatment for STDs
• Referral to therapy services;
counseling; and groups for longer-term
help
Community Violence
Of great concern are homicides and
suicides associated with schools.
Solutions emphasize:
• Problem-solving skills, anger management,
and social skills development
• Parenting programs that promote strong
bonding between parents and children and
conflict management in the home
• Mentoring programs for young people
Community Violence (cont’d)

A history of violence, victimization, and

witnessing of violence can lead to
problems with aggression, depression,
relationships, achievement, and abuse
of drugs and alcohol.
Psychiatric Disorders Related to
Abuse and Violence

Two psychiatric disorders are associated

with histories of violence and abuse:
1.Posttraumatic stress disorder (PTSD)
2.Dissociative disorders
Psychiatric Disorders Related to
Abuse and Violence (cont’d)
PTSD
Disturbing behavior resulting after a
traumatic event at least 3 months after
the trauma occurred
Up to 60% of persons at risk (combat
veterans, victims of violence and natural
disasters) develop PTSD.
Symptoms of PTSD include:
• Persistent nightmares
• Memories
• Flashbacks
• Emotional numbness
• Insomnia
• Irritability
• Hypervigilance
• Angry outbursts
Psychiatric Disorders Related to
Abuse and Violence (cont’d)
Dissociative Disorders
Dissociation is a subconscious defense
mechanism that helps a person protect the
emotional self from recognizing the full
impact of some horrific or traumatic event by
allowing the mind to forget or remove itself
from the painful situation or memory.
Dissociation can occur both during and after
the event and becomes easier with repeated
use.
Psychiatric Disorders Related to
Abuse and Violence (cont’d)
Dissociative Disorders
Dissociation is a subconscious defense
mechanism that helps a person protect the
emotional self from recognizing the full
impact of some horrific or traumatic event by
allowing the mind to forget or remove itself
from the painful situation or memory.
Dissociation can occur both during and after
the event and becomes easier with repeated
use.
Psychiatric Disorders Related to Abuse
and Violence (cont’d)

Dissociative disorders include:

• Amnesia
• Fugue
• Dissociative identity disorder (formerly
multiple personality disorder)
• Depersonalization disorder
Psychiatric Disorders Related to
Abuse and Violence (cont’d)
Treatment and Interventions
• Involvement in group and/or
individual therapy in the community
• Clients with dissociative disorder or
PTSD are seen in the acute setting
for brief periods when symptoms are
severe or there is concern for their
safety
Application of the Nursing Process
Assessment
• Includes history of trauma or abuse
• Client often appears hyperalert, anxious, or
agitated
• Mood and affect: client is fearful and
anxious; needs large personal space; has a
wide range of emotions
• Thought processes and content: nightmares,
flashbacks, destructive thoughts or impulses
Application of the Nursing Process
(cont’d)
Assessment (cont’d)
• Sensorium and intellectual processes:
disorientation (during flashbacks), memory gaps
• Judgment and insight: impaired decision-making
and problem-solving abilities
• Self-concept: client has low self-esteem
• Roles and relationships: problems with
relationships, work, authority figures
• Physiologic considerations: difficulty sleeping,
under- or overeating, use of alcohol or drugs for
self-medication
Application of the Nursing Process
(cont’d)
Data Analysis
Nursing diagnoses include:
• Risk for Self-Mutilation
• Ineffective Coping
• Post-Trauma Response
• Chronic Low Self-Esteem
• Powerlessness
Application of the Nursing Process
(cont’d)
Outcome Identification
The client will:
• Be physically safe
• Distinguish between self-harm ideas and taking
action on those ideas
• Learn healthy ways to deal with stress
• Express emotions nondestructively
• Establish social support network in the
community
Application of the Nursing Process
(cont’d)
Intervention
• Promoting the client’s safety
• Helping the client cope with stress and
emotions using grounding techniques
• Helping to promote the client’s self-
esteem
• Establishing social support
Application of the Nursing Process
(cont’d)
Evaluation
Is the patient:
• Learning to protecting him- or herself?
• Learning to manage stress and
emotions?
• Able to function in their daily lives?
Self-Awareness Issues
• Becoming comfortable asking all
women about abuse (SAFE questions)
• Listening to accounts of abuse from
clients and families
• Recognizing client’s strengths, not just
problems
• Working with perpetrators of abuse;
dealing with own feelings about abuse
and violence