Chapter 11 Abuse and Violence

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Chapter 11Abuse and Violence
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Abuse and Violence

• Violent and abusive behavior has been identified
  as a major health concern in the U.S. Abuse is
  the wrongful use and maltreatment of another
  person can be a child, spouse, partner, or
  elder parent. CDC has been studying homicides and
  suicides associated with schools.
• The single best predictor of aggressive behavior
  by a client is History of violence

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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 that might
  include
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt

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Clinical Picture of Abuse and Violence (contd)

• Feelings of being degraded or dehumanized low
  self-esteem
• Relationship problems mistrust of authority
  figures-Erikson-Trust vs Mistrust

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Characteristics of Violent Families

• Social isolation
• Power and control by abusive person
• Alcohol and other drug use
• Intergenerational transmission process

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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.

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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.
  Rates of violence same between heterosexual
  partners

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Spouse or Partner abuse cont

• Abusive man believes woman belongs to him, is
  immature and needy, feels inadequate, has low
  self-esteem, and is jealous, even of his
  children.
• Abused woman is often dependent personally and
  financially on the abuser, has low self-esteem,
  feels responsible for making the relationship
  work, may fear for her life.
• Women have difficulty leaving abusive
  relationships because of financial and emotional
  dependence.
• Women in battering relationships often remain in
  those relationships as a result of faulty or
  incorrect beliefs. The belief that is valid If
  she tried to leave, she would be at increased
  risk for violence.

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• 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

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• 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

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• 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.

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• Treatment and Intervention (contd)
• 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.

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Child Abuse

• Child abuse is intentional injury of a child. It
  may include 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), or psychological abuse- emotional
  abuse most difficult to treat. All states have
  mandatory child abuse reporting laws that include
  nurses.

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• Parents who abuse children
• Have minimal parenting knowledge 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
• Sexual abuse of a child-you might suspect if you
  hear the child telling sexually explicit stories
  to peers

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• 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

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• Treatment and Intervention-If you suspect-
  Consult with a Professional member of the health
  team about making a report
• 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

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Elder Abuse

• Elder abuse is maltreatment of older adults by
  family members or caretakers and can include
  physical, sexual, or psychological abuse,
  neglect, self-neglect, financial exploitation, or
  denial of adequate medical treatment.
• 60 perpetrators are spouses, 20 adult children,
  20 others.
• People who abuse elders are almost always in a
  caretaker role.

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Elder Abuse (contd)

• Elders are reluctant to report abuse because they
  fear the alternative (nursing home).
• Not all states have mandatory elder abuse
  reporting laws.

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• Assessment-of an edlerly neglected client-most
  common problem seen malnutrition
• Possible indicators of physical abuse
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical appointments
• Untreated medical condition

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• Possible indicators of emotional or
  psychological abuse
• Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation

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• 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

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• 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

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• 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

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• Treatment and Intervention
• Treatment and intervention may involve providing
  adequate support and respite for the caregivers,
  changing caregiving arrangements, or moving the
  elderly person to a safe environment.

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Rape

• Rape is a crime of violence and aggression
  expressed through sexual means. The act is
  against the victims will or against someone who
  cannot give consent. 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.

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• 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
• The motivation dynamic for most perpetrators of
  rape is the desire to control or degrade
  victims.

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• Physical and psychological trauma to rape
  victims is severe
• Medical problems victims are significantly less
  healthy pregnancy, STDs, HIV are concerns.
• Victim may feel frightened, helpless, guilty,
  humiliated, and embarrassed may avoid previously
  pleasurable activities.
• Relationship problems may occur.
• Hx of sexual abuse might expect and experience
  nightmares and flashbacks

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• Treatment and intervention include
• Immediate support to ventilate fear and
  rage-expect the woman may feel threatened by
  some of the procedure
• Care by persons who believe that the rape
  happened
• Coordination of all needed services in one
  location

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• Treatment and intervention include
• Giving the victim control over choices whenever
  possible
• Prophylactic treatment for STDs
• Referral to therapy services counseling, and
  groups for longer-term help
• A frightened young woman calls the emergency
  Dept. and tearfully tells the nurse Ive been
  raped! Please help me!-Before telling the client
  what to do, you the nurse need to knowIf the
  client was injured, in a safe place, and had
  transportation available.

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Psychiatric Disorders Related to Abuse and
Violence

• Two psychiatric disorders are associated with
  histories of violence and abuse posttraumatic
  stress disorder (PTSD) and dissociative
  disorders.

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Psychiatric Disorders Related to Abuse and
Violence (contd)

• PTSD
• Is 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. It includes
  persistent nightmares, memories, flashbacks,
  emotional numbness, insomnia, irritability,
  hypervigilance, and angry outbursts.

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• 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.

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• Amnesia
• Fugue
• Dissociative identity disorder (formerly multiple
  personality disorder)
• Depersonalization disorder

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• 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.
• A client with Dissociative Identity disorder
  having flashbacks-nurses responsibility Is best
  not to touch the client without his or her
  permisssion.

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Application of the Nursing Process

• Assessment
• Often includes history of trauma or abuse
• Client often appears hyperalert.
• 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

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• Assessment (contd)
• 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

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• Data Analysis
• Nursing diagnoses include
• Risk for Self-Mutilation
• Ineffective Coping
• Post-Trauma Syndrome
• Chronic Low Self-Esteem
• Powerlessness

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• 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
• Establishing social support network in the
  community

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• Intervention
• Promoting the clients safety
• Helping the client cope with stress and emotions
  using grounding techniques-Client having a
  flashback-nurse states I know you scared, but
  youre in a safe place. Do you see the bed in
  your room? Do you feel the chair you are sitting
  in?
• Helping to promote the clients self-esteem
• Establishing social support
• MANAGE STRESS BY JOURNALING IF THEY ARE HAVING
  DIFFICULTY EXPRESSING FEELINGS

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Self-Awareness Issues

• Becoming comfortable asking all women about abuse
  (SAFE questions)
• Listening to accounts of abuse from clients and
  families
• Recognizing clients strengths, not just problems
  
• Working with perpetrators of abuse dealing with
  own feelings about abuse and violence