ABUSE & VIOLENCE CHAPTER 55 (ASIO) - Stress has a greater impact on individuals who do not

have strong support people around them

Abuse - To prevent an abuse, a child may assume a role
- Willful injury reversal with the parent of become the comforting,
- Intentional solacing person
- Long term consequences
- 30% children from abusive parents are more likely to
be one Reporting Suspected Child Abuse
- Nurses are the first one to recognize who are abused
2 types of responsibility in reporting child abuse

1. Mandatory reporters
Nursing Care of Family in Crisis: 2. Permissive reporters

CHILD ABUSE Nurses are included in the mandatory category in most states:
they must report suspected child abuse when they identify it.
- may be physical or neglect, psychological or even
emotional A. Physical Abuse
- Has immediate risk but can also lead to long-term
effects - action of a caregiver that causes injury to a child
- Commonly revealed by burns or by injuries to the
Behaviors of abused child: head or hands

- Aloof
- Angry
- Irritable
- Noncompliant
- Hyperactive
- Low self esteem
- Poor self-control
THEORIES OF CHILD ABUSE: (Special Triad)
SPECIAL PARENT: PARENTS WHO ABUSE
- seem a little different from others
- Only a small fraction of them ha e a history of mental
illness but many of them were abused as children
- Have less self-control
- May be unfamiliar with the normal growth &
development of children and have many unrealistic
expectations of a child
- May be socially isolated, with no support people
readily available & so can become overwhelmed by
childbearing
- Abuse is strongly a/w excessive parental use of
alcohol, a substance that removes inhibitions and
self-control
SPECIAL CHILD: CHILDREN WHO ARE ABUSED
- viewed as somehow “different” by their parents
- May be more or less intelligent than other children in
the family
- May have a birth defect; may have an attention span
deficit
SPECIAL CIRCUMSTANCES: STRESS
- may be a result to an event that would not necessarily
be stressful for an average parent like a blocked toilet
or an illness in the family
Assessment
- done by interviewing the parents about an injury to a
child’s body
- Some injuries may be due to unintentional accidents
caused by the child’s inability to distinguish safe
situations from dangerous ones
- If a child has been physically abused, the injury is
usually out of proportion to the history of the injury
given by the parent
- Parents may give conflicting stories or may give no
reason for the injury
- Abused children often repeat the parent’s story
Physical examination
- make sure the child is fully undressed so that the
entire body can be observed
- Plot height & weight on a standard growth chart
(delayed growth = neglect)
Common findings
- beaten with electrical cords, belts or clotheslines -
circular or linear lesions
- Belt buckle or other weapons - curved laceration or
contusions
- Tied to a bed or against a wall - abrasions or
ecchymotic areas on the wrists or ankles
- Burns - dorsal surface of their hands
- Scalding with hot water - ring of burns causing a
“doughnut-hole” effect
- Cigarette burns - if fresh, blister is seen that
resembles the scab or impetigo. If healed, a definite
circular scar is observed
- Broken bones - multiple fracture in different stages of
healing, a single fracture with multiple bruises, rib or
occipital fractures, and metaphyseal-epiphyseal
injuries
 - Deliberate poisoning - usually occurs in a child
younger than 2.5 yrs old
Nursing Diagnosis and Related Interventions
- Nursing diagnosis: Risk for injury RT documented
abused by parent
- Outcome evaluation: child has no further physical
injuries identifiable as being inflicted by abusing
parent
- Interventions:
• prevent further abuse
• Identify abusive parents
• Provide consistent care and support for
abused child (consistency & security)
• Evaluate and promote family health
B. Ritual Abuse
- a cult based or religiously, spiritually or satanically
motivated
- Can involve physical, sexual or psychological abuse
with bizarre or ceremonial activities
C. Physical Neglect
- a more subtle form of abuse than physical abuse, but
it can be just as damaging to a child’s welfare
- Child may appear unwashed, thin & malnourished or
be dressed inappropriately
- Ex. Not requiring child to go to school
D. Psychological Abuse
- constant belittling or threatening, rejecting, isolating
or exploiting a child
- Abused child is likely to have difficulty becoming
emotionally confident adults
- Most difficult form abuse to detect - may occur only
at home
SEXUAL ABUSE
- any sexual contact between a child and an adult
- Involves the coercion of dependent, developmentally
immature children and adolescents in sexual activities
that they do not fully comprehend, to which they are
unable to give informed consent, or that violate the
social taboos of family roles
- Is physically or emotionally destructive; it leaves
children unable to trust others, and they have a sense
of ambivalence toward intimacy and an overall sense
of worthlessness
A. Molestation
- a vague term that includes “indecent liberties” such
as oral-genital fondling and viewing or masturbation
- Pedophile - adult who seeks out children fir sexual
gratification
B. Incest
- sexual activity between family members
- Often involves an older man and a young girl,
although it may involve and older woman and a
younger boy, a brother and sister, or same-sex
partners
- Results in a destructive relationship because it causes
a great deal of guilt and loss of self-esteem in both the
abusing and the abused person
C. Pornography and Prostitution
- child pornography - photographing or describing
sexual acts by any media involving children, or
distributing such material in person or by mail or fax
or over the internet
- Child prostitution - arranging or participating in sexual
acts with children
Assessment
- verbal reports of sexual activity with an adult
- Awareness of sex and sexual vocabulary beyond age
expectations
- Participation in sexual expression with dolls
- Pregnancy in a girl younger than 15 years of age
- Perineal, vaginal or anal inflammation
- Vaginal tears or anal fissures
- Presence of STIs
- Asking child to draw what happened
- Sx: increased anxiety such as sleep disturbance,
development of tics, nail biting or stuttering
- Change in school performance, school phobia or
truancy
- Fear of being left alone with a certain adult
- Vague abdominal pain or acting-put behavior
Therapeutic management
- Report immediately to authorities
- Psychological counselling for both the adult & child -
to improve child’s self-esteem & let adult admit his
fault
- Treatment for STIs
- Encourage parents to teach children some simple
rules ti help then avoid sexual abuse
RAPE
- Sexual activity that occurs under actual or threatened
force
- Forcible rape - intercourse or penetration of a body
orifice by a penis or other object
- Statutory Rape - sexual activity with a person under
the age of consent
 - Sexual assault - refer to other forces sexual acts, such
as oral-genital or anal-genital acts
- Date Rape – indiv. forces a date or casual friend into
having coitus despite voiced unwillingness.
Assessment
2 stages pf rape trauma Syndrome:
1. Disorganization phase - victims feel a combination of
humiliation, shame and guilt, embarrassment, anger
and vengefulness; 3 days
2. Reorganization phase - may last for months or years
and report recurring nightmares, perhaps sexual
dysfunction, and continuing inability to relate to men
or face new surprising situations
- Silent rape syndrome - experienced by those who do
not report rape and receive no counseling
Emergency care
- Describe the victim’s physical appearance
- Gynecologic or anal examination
- Presence of acid phosphate
- Vaginal and anal cultures
- Pregnancy test
- VDRL test for syphilis
- Prophylactic administration of antibiotics against
gonorrhea and syphilis
- Oral contraceptives to avoid pregnancy
Legal considerations
- Nurses can testify
- Chart is a legal document and can be used in court
Nursing Diagnosis and Related Interventions:
1. Nursing diagnosis: Rape Trauma Syndrome r/t recent
rape
• Outcome evaluation: victim is able to discuss what
happened and voice intense feelings about the crime;
victim states ability to go forward with life
• Interventions:
- Ask the victim to describe the incident to you
- Counseling
- Follow up testing and care
2. Nursing Diagnosis: Disabling family coping r/t recent
rape of family member
• Outcome evaluation:
- partner or other family members express
feelings about the rape to health care
provider; states confidence in ability to
support rape victim
• Intervention:
- Counseling
INTIMATE PARTNER ABUSE
- abuse by a family member against other individuals
living in the household, such as spouse child, parent
or grandparent
- Children who are exposed to intimate partner abuse
may demonstrate conduct problems, noncompliance
and aggression
- They may display distress behaviors such as clinging,
crying, abdominal pain or sleeping disorders
Theories About Intimate Partner Abuse:
1. Violence preceded the relationship or children
- Violence is usually brought into the family by a man
with a history of violence
- His violence-prone characteristics usually erupt early
in the courtship and grow progressively worse
- 3 phases in the cycle of violence
a. Tension-building
b. Acute violence
c. “Honeymoon” or tranquil, loving phase
2. Violence developed after the relationship was
established or children were born
- violence develops as a last resort after all other
attempts at communication have failed
- The behavior of one partner threatens the
psychological defenses of the other, and each
projects his or her feelings and shortcomings onto the
other.
Assessment
- ask about the possibility of abuse since 20-25% of
women seen in emergency departments for trauma
received their wounds from abuse
- Common injuries suffered by abused woman are
burns, bruises, and head injuries.
- Physical examination helps detect physical abuse
while emotional abuse can be detected by asking
about their safety or well-being.
Therapeutic Management
- don’t blame the victims
- Help them find a shelter where they can feel safe
- Treatment for abusers needs to be scheduled, but
safety is first priority