NCM 117

ABUSE AND VIOLENCE

SABIO

ABUSE AND VIOLENCE o Ask permission before touching him or

INTRODUCTION
• Victims of abuse or violence certainly can have
physical injuries needing medical attention, but
they also experience psychological injuries with
a broad range of responses.
o Some clients are:
§ Agitated
§ Visibly upset
§ Withdrawn
§ Aloof
§ Appearing numb
§ Oblivious to their surroundings
• Often, domestic violence remains undisclosed for
months or even years because victims fear their
abusers.
• Victims frequently suppress their anger and
resentment and do not tell anyone.
o This is particularly true in cases of
childhood sexual abuse.
• Children particularly come to believe that
somehow, they are at fault and did something
to deserve or provoke the abuse.
o They are more likely to:
§ Miss school
§ Less likely to attend college.
§ Continue to have problems
through adolescence into
adulthood.
• As adults, they usually feel guilt or shame for
not trying to stop the abuse.
o Survivors feel:
§ Degraded
§ Humiliated
§ Dehumanized
§ Very low self-esteem
§ View themselves as
unlovable.
§ They believe they are
unacceptable to others,
contaminated, or ruined.
Depression, suicidal behavior, and marital and sexual
difficulties are common. (National Institutes of Health,
2006).
• Victims and survivors of abuse may have
problems relating to others. They find trusting
others, especially authority figures, to be difficult.
• In relationships, their emotional reactions are
likely to be:
o Erratic
o Intense
o Perceived unpredictable
• Intimate relationships may trigger extreme
emotional responses such as:
o Panic
o Anxiety
o Fear
o Terror
o Even responses such as spouse desire
closeness with another person, they
may perceive actual closeness as
intrusive and threatening.
• Nurses should be particularly sensitive to the
abused client's need to feel safe, secure, and in
control of his or her body.
o They should take care to maintain the
client's personal space
o Assess the client’s anxiety level
her for any reason.
• Because the nurse may not always be aware of a
history of abuse when initially working with a client,
he or she should apply these cautions to all clients
in the mental health setting (Videbeck, S., 2008;
p.189).
INTRODUCTION
• Family and domestic violence including child
abuse, intimate partner abuse, and elder abuse
is a common problem in the United States.
• Estimated to affect 10 million people in the United
States every year.
• It is a national public health problem, and virtually
all healthcare professionals will at some point
evaluate or treat a patient who is a victim of some
form of domestic or family violence.
• Unfortunately, each form of family violence begets
interrelated forms of violence.
• The "cycle of abuse" is often continued from
exposed children into their adult relationships and
finally to the care of the elderly.
• Domestic and family violence includes a range
of abuse toward children, adults, and elders.
o Economic
o Physical
o Sexual
o Emotional
o Psychological
• Intimate partner violence includes:
o Stalking
o Sexual violence
o Physical violence
o Psychological aggression by a current or
former partner.
• In the United States, as many as one in four
women and one in nine men are victims of
domestic violence.
• Domestic violence is thought to be underreported.
Domestic violence affects:
o Victims
o Families
o Co-workers
o Community
• It causes diminished psychological and physical
health, decreases the quality of life, and results in
decreased productivity.
• Domestic and family violence is difficult to identify,
and many cases go unreported to health
professionals or legal authorities.
• Due to the prevalence in our society, all healthcare
professionals, including psychologists, nurses,
pharmacists, dentists, physician assistants, nurse
practitioners, and physicians, will evaluate and
possibly treat a victim or perpetrator of domestic or
family violence.
DEFINITIONS
Family and domestic violence are abusive behaviors in
which one individual gains power over another individual.
INTIMATE PARTNER VIOLENCE
• Typically includes:
o Sexual violence
o Physical violence
o Psychological aggression

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o Stalking (may include former or current
partners)
CHILD ABUSE
• Involves the emotional, sexual, and physical, or
neglect of a child under 18 by a parent, custodian, or
caregiver that results in potential harm, harm, or a
threat of harm.
ELDER ABUSE
• A failure to act or an intentional act by a caregiver that
causes or creates a risk of harm to an elder.
• Domestic and family violence has no boundaries.
• This violence occurs in intimate relationships regardless
of culture, race, religion, or socioeconomic status.
• All healthcare professionals must understand that
domestic violence, whether in the form of emotional,
psychological, sexual, or physical violence, is common
in our society and should develop the ability to
recognize it and make the appropriate referral.
VIOLENCE ABUSE TYPES
• Stalking
• Economic
• Emotional
• Psychological
• Neglect
• Munchausen by proxy
• Physical
• Domestic and family violence occurs in all races,
ages, and sexes.
• It knows no cultural, socioeconomic, education,
religious, or geographic limitation.
• It may occur in individuals with different sexual
orientations.
ETIOLOGY
REASON ABUSERS NEED TO CONTROL:
• Anger management issues
• Jealousy
• Low self-esteem
• Feeling inferior
• Cultural beliefs they have the right to control their
partner.
• Personality disorder or psychological disorder
• Learned behavior from growing up in a family
where domestic violence was accepted.
• Alcohol and drugs, as an impaired individual may
be less likely to control violent impulses.
RISK FACTORS
• Risk factors for domestic and family violence:
o Individual issues
o Relationship issues
o Community issues
o Societal issues
• There is an inverse relationship between
education and domestic violence.
• Lower education levels correlate more likely
with domestic violence.
• Childhood abuse is commonly associated with
becoming a perpetrator of domestic violence
as an adult.
• Drug and alcohol abuse greatly increases the
incidence of domestic violence.
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EPIDEMIOLOGY
• Domestic violence is a serious and challenging
public health problem.
• Approx. 1 in 30 women and 1 in 10 men in 18
years of age or older experience domestic
violence.
• Domestic violence victims typically experience
severe physical injuries requiring care at a hospital
or clinic.
• The cost to individuals and society is significant.
• The national annual cost of medical and mental
health services related to acute domestic violence
is estimated at over $8 billion.
• If the injury results in a long-term or chronic
condition, the cost is considerably higher.
• Financial hardship and unemployment are
contributors to domestic violence.
• An economic downturn is associated with
increased calls to the National Domestic Violence
Hotline. Fortunately, the national rate of nonfatal
domestic violence is declining. This is thought to
be due to a decline in the marriage rate,
decreased domesticity, better access to domestic
violence shelters, improvements in female
economic status, and an increase in the average
age of the population.
NATIONAL
• Most perpetrators and victims do not seek
help.
• Healthcare professionals are usually the first
individuals with an opportunity to identify
domestic violence.
• Nurses are usually the first healthcare
providers victims encounter.
• Domestic violence may be perpetrated on
women, men, parents, and children.
• 50% of women seen in emergency
departments report a history of abuse, and
approx. 40% of those killed by their abuser
sought help in the 2 years before death.
• Only 1/3 of police-identified victims of
domestic violence are identified in the
emergency department.
• Healthcare professionals who work in acute
care need to maintain a high index of
suspicion for domestic violence as supportive
family members may, in fact, be abusers.
CHILD ABUSE
• Age, family income, and ethnicity are all risk
factors for both sexual abuse and physical abuse.
• Gender is a risk factor for sexual abuse but not
for physical abuse.
• Each year there are over 3 million referrals to child
protective authorities.
• Despite often being the first to examine the
victims, only about 10% of the referrals were from
medical personnel.
• The fatality rate is approximately two deaths per
100,000 children. Women account for a little over
half of the perpetrators.
INTIMATE PARTNER VIOLENCE
• According to the CDC, 1 in 4 women and 1 in 7
men will experience physical violence by their
intimate partner at some point during their
lifetimes.
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• About 1 in 3 women and nearly 1 in 6 men
experience some form of sexual violence during
their lifetimes.
• Intimate partner violence, sexual violence, and
stalking are high, with intimate partner violence
occurring in over 10 million people each year.
• One in 6 women and 1 in 19 men have
experienced stalking during their lifetimes. The
majority are stalked by someone they know.
• An intimate partner stalks about 6 in 10 female
victims and 4 in 10 male victims.
• At least 5 million acts of domestic violence occur
annually to women aged 18 years and older, with
over 3 million involving men.
• While most events are minor, for example:
o Grabbing
o Shoving
o Pushing
o Slapping
o Hitting
o Serious and sometimes fatal injuries do
occur.
• Approximately 1.5 million intimate partner female
rapes and physical assaults are perpetrated
annually, and approximately 800,000 male
assaults occur.
• About 1 in 5 women have experienced completed
or attempted rape at some point in their lives.
• About 1% to 2% of men have experienced
completed or attempted rape.
• The incidence of intimate partner violence has
declined by over 60%, from about ten
victimizations per 1000 persons age 12 or older to
approximately 4 per 1000.
ELDERLY
• Due to underreporting and difficulty sampling,
obtaining acute incidence information on elder
abuse and neglect is difficult.
• Elderly abuse is thought to occur in 3-10% of the
population of elders.
• Elderly patients may not report due to fear,
guilt, ignorance, or shame.
• Clinicians underreport elder abuse due to poor
recognition of the problem, lack of understanding
of reporting methods and requirements, and
concerns about physician-patient confidentiality.
PATHOPHYSIOLOGY
• There may be some pathologic findings in both the
victims and perpetrators of domestic violence.
• Certain medical conditions and lifestyles make
family and domestic violence more likely.
• While the research is not definitive, a number of
characteristics are thought to be present in
perpetrators of domestic violence. Abusers tend to:
o Have a higher consumption of alcohol
and illicit drugs
§ Assessment should include
questions that explore
drinking habits and violence.
o Be possessive, jealous, suspicious, and
paranoid.
o Be controlling of everyday family activity,
including control of finances and social
activities.
o Suffer low self-esteem.
o Have emotional dependence
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§ Which tends to occur in both
partners, but more so in the
abuser.
CHILDREN
• Domestic violence at home results in
emotional damage, which exerts continued
effects as the victim matures.
• Approximately 45 million children will be exposed
to violence during childhood.
• Approximately 10% of children are exposed to
domestic violence annually, and 25% are exposed
to at least 1 event during their childhood.
• Ninety percent are direct eyewitnesses of violence.
• Males who batter their wives batter the children
30% to 60% of the time.
• Children who witness domestic violence are at
increased risk of dating violence and have a
more difficult time with partnerships and
parenting.
• Children who witness domestic violence are at an
increased risk for:
o Post-traumatic stress disorder
o Aggressive behavior
o Anxiety
o Impaired development
o Difficulty interacting with peers
o Academic problems
o Have a higher incidence of substance
abuse.
• Children exposed to domestic violence often
become victims of violence.
• Children who witness and experience domestic
violence are at a greater risk for adverse
psychosocial outcomes.
• Eighty to 90% of domestic violence victims abuse
or neglect their children.
• Abused teens may not report abuse.
• Individuals 12 to 19 years of age report only about
one-third of crimes against them, compared with
one-half in older age groups.
PREGNANT AND FEMALES
• The American College of Obstetricians and
Gynecologists (ACOG) recommends all women be
assessed for signs and symptoms of domestic
violence during regular and prenatal visits.
• Providers should offer support and referral
information.
• Domestic violence affects approximately 325,000
pregnant women each year.
• The average reported prevalence during
pregnancy is approximately 30% emotional abuse,
15% physical abuse, and 8% sexual abuse.
• Domestic violence is more common among
pregnant women than preeclampsia and
gestational diabetes.
• Reproductive abuse may occur
o Includes impregnating against a
partner's wishes by stopping a partner
from using birth control.
• Since most pregnant women receive prenatal
care, this is an excellent time to assess for
domestic violence.
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• The danger of domestic violence is particularly • The annual incidence of elder abuse is estimated
acute as both mother and fetus are at risk. to be 2% to 10%, with only about 1 in 15 cases
• Healthcare professionals should be aware of the reported to the authorities.
psychological consequences of domestic abuse • Approximately one-third of nursing homes
during pregnancy. disclosed at least 1 incident of physical abuse per
• There is more stress, depression, and addiction to year.
alcohol in abused pregnant women. These • Ten percent of nursing home staff self-report
conditions may harm the fetus. physical abuse against an elderly resident.
• Elder domestic violence may be financial or
GAY, LESBIAN, BISEXUAL, AND TRANSGENDER
physical.
• Domestic violence occurs in gay, lesbian, bisexual,
• The elderly may be controlled financially.
and transgender couples, and the rates are
• Elders are often hesitant to report this abuse if
thought to be similar to a heterosexual woman,
it is their only available caregiver.
approximately 25%.
• Victims are often:
• There are more cases of domestic violence
o Dependent
among males living with male partners than
o Infirm
among males who live with female partners. o Isolated
• Females living with female partners experience o Mentally impaired
less domestic violence than females living with • Healthcare professionals should be aware of the
males. high incidence of abuse in this population.
• Transgender individuals have a higher risk of • The history and physical exam should be tailored
domestic violence. to the age of the victim.
• Transgender victims are approximately two
times more likely to experience physical HISTORY AND PHYSICAL
violence. CHILD ABUSE
• Gay, lesbian, bisexual, and transgender victims • The most common injuries are:
may be reticent to report domestic violence. o Fractures
• Part of the challenge may be that support services o Contusions
such as shelters, support groups, and hotlines are o Bruises
not regularly available. o Internal bleeding
o This results in isolated and unsupported • Unexpected injuries to pre-walking infants should
victims. be investigated.
• Healthcare professionals should strive to be • The caregiver should explain unusual injuries to
helpful when working with gay, lesbian, bisexual, the ears, neck, or torso; otherwise, these injuries
and transgender patients. should be investigated.
• Children who are abused may be unkempt and/or
MEN malnourished.
• Usually, domestic violence is perpetrated by men • They may display inappropriate behavior such as:
against women; however, females may exhibit o Aggression
violent behavior against their male partners. o Maybe shy
• Approximately 5% of males are killed by their o Withdrawn
intimate partners. o Has poor communication skills
• Each year, approximately 500,000 women are o Disruptive
physically assaulted or raped by an intimate o Hyperactive
partner compared to 100,000 men. o School attendance is usually poor
• Three out of 10 women at some points are stalked,
INTIMATE PARTNER ABUSE
physically assaulted, or raped by an intimate
• Approximately one-third of women and one-fifth of
partner, compared to 1 out of every 10 men. men will be victims of abuse.
• Rape is primarily perpetrated by other men, • The most common sites of injuries:
while women engage in other forms of violence o Head
against men. o Neck
• Although women are the most common victims of o Face
domestic violence, healthcare professionals • Clothes may cover injuries to the body, breasts,
should remember that men may also be victims genitals, rectum, and buttocks.
and should be evaluated if there are indications • One should be suspicious if the history is not
present. consistent with the injury.
• Defensive injuries may be present on the forearms
ELDERLY and hands.
• The elderly are often mistreated by their spouses, • The patient may have psychological signs and
children, or relatives. symptoms such as:
• Annually, approx. 2% of the elderly experience o Anxiety
physical abuse; o Depression
o 1% sexual abuse o Fatigue
o 5% neglect • Medical complaints may be specific or vague such
o 5% financial abuse as:
o 5% suffer emotional abuse o Headaches
o Palpitations

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o Chest pain • The evaluation should start with a detailed history

o Painful intercourse and physical examination.
o Chronic pain o Clinicians should screen all females for
domestic violence and refer females
INTIMATE PARTNER ABUSE: PRGNANCY AND FEMALE who screen positive. This includes
• Abuse during pregnancy may cause as much as females who do not have signs or
10% of pregnant hospital admissions. symptoms of abuse.
• There are a number of historical and physical o All healthcare facilities should have a
findings that may help the provider identify plan in place that provides for
individuals at risk. assessing, screening, and referring
• If the examiner encounters signs or symptoms, patients for intimate partner violence.
she should make every effort to examine the o Protocols should include:
patient in private, explaining confidentiality to the § Referral
patient. § Documentation
• Be sure to ask caring, empathetic questions and § Follow-ups
listen politely without interruption to answers. • Health professionals and administrators should be
aware of challenges such as barriers to screening
INTIMATE PARTNER ABUSE: SAME-SEX for domestic violence:
• Same-sex partner abuse is common and may be o Lack of training
difficult to identify. o Time constraints
• Over 35% of heterosexual women o Sensitive nature of issues
• 40% of lesbians o Lack of privacy to address the issues
• 60% of bisexual women experience domestic • Although professional and public awareness has
violence increased, many patients and providers are still
• For men, the incidence is slightly lower. hesitant to discuss abuse.
• In addition to common findings of abuse, • Patients with signs and symptoms of domestic
perpetrators may try to control their partners by violence should be evaluated. The obvious cues
threatening to make their sexual preferences are physical:
public. o Bruises
• The provider should be aware there are fewer o Bites
resources available to help victims; further, the o Cuts
perpetrator and victim may have the same friends o Broken bones
or support groups. o Concussions
o Burns
INTIMATE PARTNER ABUSE: MEN o Knife or GSW
• Men represent as much as 15% of all cases of • Typical domestic injury patterns include contusions
domestic partner violence. to the:
o Head
• Male victims are also less likely to seek medical
o Face
care, so that the incidence may be underreported.
o Neck
• These victims may have a history of child abuse.
o Breast
o Chest
ELDERLY ABUSE
o Abdomen
• Health professionals should ask geriatric patients o Musculoskeletal injuries
about abuse, even if signs are absent.
• Accidental injuries more commonly involve the
• Risk factors: extremities of the body.
o Dementia
• Abuse victims tend to have multiple injuries in
o Pathologic characteristics of
various stages of healing, from acute to
perpetrators including:
chronic.
§ Dementia
• Domestic violence victims may have emotional
§ Mental illness
and psychological issues such as anxiety and
§ Drug abuse
depression.
§ Alcohol abuse
o A shared living situation with the abuser • Complaints may include:
o Social isolation o Backaches
o Stomachaches
EVALUATION o Headaches
o Fatigue
• Establishing that injuries are related to domestic
o Restlessness
abuse is a challenging task.
o Decreased appetite
• Life and limb threatening injuries are the
o Insomnia
priority.
• Women are more likely to experience:
• After stabilization and physical examination, these
o Asthma
may be indicated:
o Irritable bowel syndrome
o Laboratory tests
o Diabetes
o X-rays
o CT scan
ASSESSMENT
o MRI
• Assuming the patient is table and not in pain, a
• It is important that healthcare professionals first
detailed assessment of victims should occur
attend to the underlying issue that brought the
after disclosure of abuse.
victim to the emergency department.

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• Assessing safety is the priority.
• A list of standard prepared questions can help
alleviate the uncertainty in the patient’s evaluation.
• If there are signs of immediate danger, refer to
advocate support, shelter, a hotline for victims,
or legal authorities.
• If there is no immediate danger, the assessment
should focus on mental and physical health and
establish the history of current or past abuse.
o These responses determine the
appropriate intervention.
• During the initial assessment, a practitioner must
be sensitive to the patient’s cultural beliefs.
o Incorporating a cultural sensitivity
assessment with a history of being
victims of domestic violence may allow
more effective treatment.
• Patients that have suffered domestic violence may
or may not want a referral.
o Many are fearful of their lives and
financial well-being.
o They may be weighing the tradeoff in
leaving the abuser leading to loss of
support and perhaps the responsibility of
caring for children alone.
o The healthcare provider needs to
assure the patient that the decision is
voluntary and that the provider will
help regardless of the decision.
o The goal is to make resources
accessible, safe, and enhance
support.
• If the patient elects to leave their current situation,
information to referral to a local domestic
violence shelter to assist the victim should be
given.
• If there is a risk to life or limb, or evidence of injury,
the patient should be referred to local law
enforcement officials.
• Counselors often include:
o Social workers
o Psychiatrists
o Psychologists
o That specialize in the care of battered
partners or children.
TESTING
CHILDREN
• A detailed history and careful physical exam
should be performed.
• If head trauma is suspected, consider an
ophthalmology consultation to obtain indirect
ophthalmoscopy.
LABORATORY
• Lab studies are often important for forensic
evaluation and criminal prosecution.
• On occasion, certain diseases may mimic
findings similar to child abuse.
o As a consequence, they must be ruled
out.
URINE
• A urine test may be used as a screen for:
o STD
o Bladder trauma
o Kidney trauma
o Toxicology screening
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HEMATOLOGY
• If bruises or contusions are present, there is
no need to evaluate for a bleeding disorder if
the injuries are consistent with an abuse
history.
• Some tests can be falsely elevated, so a child
abuse-specialist pediatrician or hematologist
should review or follow-up these tests.
GASTROINTESTINAL AND CHEST TRAUMA
• Consider liver and pancreas screening tests such
as:
o AST
o ALT
o Lipase
o If the AST or ALT is greater than 80
IU/L, or lipase is greater than 100
IU/L, consider an abdomen and pelvis
CT with intravenous contrast.
• The highest risk are those with:
o Head trauma
o Fractures
o Nausea
o Vomiting
o Abdominal Glasglow Coma Scale score
of less than 15.
IMAGING
• The evaluation of the pediatric skeleton can prove
challenging for a non-specialist as there are subtle
differences from adults such as:
o Cranial sutures
o Incomplete bone growth
• A fracture can be misinterpreted
• If there is a concern for abuse, consider consulting
a radiologist.
IMAGING: SKELETAL SURVEY
• A skeletal survey is indicated in children
younger than 2 years with suspected physical
abuse.
• The incidence of occult fractures is as high as 1 in
4 in physically abused children younger than 2
years.
• The clinician should consider screening all siblings
younger than 2 years.
• The skeletal survey should include 2 views of each
extremity:
o Anteroposterior and lateral skull
o Lateral chest
o Spine
o Abdomen
o Pelvis
o Hands
o Feet
• A radiologist should review the films for classic
metaphyseal lesions and healing fractures, most
often involving the posterior ribs.
• A “babygram” that includes only 1 film of the
entire body is not an adequate skeletal survey.
• Skeletal fractures will remodel at different rates,
which are dependent on the:
o Age
o Location
o Nutritional status of the patient
IMAGING: CT
• If abuse or head trauma is suspected, a CT scan
should be performed on all children aged 6
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months or younger or children younger than • Clothing stained with blood, saliva, semen, and
24 months if intracranial trauma is suspected. vomit should be retained for forensic analysis.
• Clinicians should have a low threshold to obtain a
CT scan of the head when abuse is suspected, TREATMENT AND ANALYSIS
especially in an infant younger than 12 months. • The priority is the ABCs and appropriate
• CT of the abdomen and pelvis with intravenous treatment of the presenting complaints.
contrast is indicated in: • Once the patient is stabilized, emergency medical
o Unconscious children services personnel may identify problems
o Have traumatic abdominal findings: associated with violence.
§ Abrasions
§ Bruises EMERGENCY DEPARTMENT AND OFFICE CARE
§ Tenderness
§ Absent or decreased bowel INTERVENTIONS TO CONSIDER:
sounds • Make sure a safe environment is provided.
§ Abdominal pain • Diagnose physical injuries and other medical or
§ Nausea surgical problems.
§ Vomiting • Treat acute physical or life-threatening injuries.
§ Have elevation of the AST, • Identify possible sources of domestic violence.
ALT (greater than 80 IU/L) • Counsel the patient that violence may escalate.
§ Lipase greater than 100 IU/L • Establish domestic violence as a diagnosis.
• Reassure the patient that he/she is not at fault.
SPECIAL DOCUMENTATION
• Evaluate the emotional status and treat.
• Photographs should be taken before treatment of
• Document the history, physical,, and interventions.
injuries.
• Determine the risks to the victim and assess safety
INTIMATE PARTNER AND ELDER options.
LABORATORY • Determine if legal intervention is needed and
• Evaluate for evidence of: report abuse when appropriate or mandated.
o Dehydration
o Electrolyte abnormalities DEVELOP A FOLLOW-UP PLAN
o Infection • Offer shelter options, legal services, counseling,
o Substance abuse and facilitate such referral.
o Improper medication administration
o Malnutrition MEDICAL RECORD
• The medical record is often evidence used to
IMAGING convict an abuser.
• X-rays of bruised of tender body parts to detect • A poorly documented chart may result in an
fractures. abuser going free and assaulting again.
• Head CT scan to evaluate for intracranial bleeding • Charting should include detailed documentation of
as a result of abuse or the causes of altered evaluation, treatment, and referrals.
mental status. • Describe the abusive event and current complaints
using patient’s own words.
OTHER • Include the behavior of the patient in the record.
• Pelvic examination with evidence collection if • Include health problems related to the abuse.
sexual assault. • Include the alleged perpetrator’s name,
relationship, and address.
EVIDENCE COLLECTION • The physical exam should include a description of
• Domestic and family violence commonly results in the patient’s injuries including:
the legal prosecution of the perpetrator. o Location
• Preferably, a team specializing in domestic o Color
violence is called in to assist with evidence o Size
collection. o Amount
• Each health facility should have a written o Degree of age bruises and contusions
procedure for how to package and label • Document injuries with anatomical diagrams and
specimens and maintain a chain of custody. photographs.
• Law enforcement personnel will often assist with o Include:
evidence collection and provide specific kits. § Name of the patient
• It is important to avoid destroying evidence. § Medical record number
• Evidence includes: § Date and time of the
o Tissue specimens photograph
o Blood § Witnesses on the back of
o Urine each photograph.
o Saliva • Torn and damaged clothing should also be
o Vaginal specimens photographed.
o Rectal specimens • Document injuries not shown clearly by
• Saliva from bites can be collected. photographs with line drawings.
o The bite mark is swabbed with a water- • With sexual assault, follow protocols for physical
moistened cotton-tipped swab. examination and evidence collection.

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DISPOSITION
• If the patient does not want to go to a shelter,
provide telephone numbers for domestic violence
or crisis hotlines and support services for potential
later use.
• Provide the patient with instructions but be mindful
that written materials may pose a danger once the
patient returns home.
• A referral should be made to primary care or
another appropriate resource.
• Advise the patient to have a safety plan and
provide examples.
!! REMEMBER !!
• 40% of domestic violence victims never contact
the police.
• Of female victims of domestic homicide, 44% had
visited a hospital emergency department within 2
years of their murder.
• Health professionals provide an opportunity for
victims of domestic violence to obtain help.
DIFFERENTIAL DIAGNOSIS
• The differential diagnosis varies with the injury,
type of injury, and age.
PROGNOSIS
• Without proper social service and mental health
intervention, all forms of abuse can be recurrent
and escalate problems, and the prognosis for
recovery is very poor.
• Without treatment, domestic and family violence
usually recurs and escalates in both frequency and
severity.
• Of those injured by domestic violence , over 75%
continue to experience abuse.
• Over half of battered women who attempt suicide
will try again.
o Often they are successful with the
second attempt.
• In children, the potential for poor outcomes is
particularly high as abuse inflicts lifelong effects.
• In addition to dealing with the sequelae of physical
injury, the mental consequences may be
catastrophic.
• Studies indicate a significant association
between child sexual abuse and increased risk
of psychiatric disorders in later life.
• The potential for the cycle of violence to continue
from childhood is very high.

CHILD CHILDREN RAISED IN FAMILIES OF SEXUAL ABUSE

HEAD TRAUMA MAY DEVELOP:
• Accidental injury • Attention deficit hyperactivity disorder (ADHD)
• Arteriovenous malformations • Conduct disorder
• Bacterial meningitis • Depression
• Birth trauma • Bipolar disorder
• Cerebral sinovenous thrombosis • Panic disorder
• Hemophilia • Sleep disorders
• Solid brain tumors • Suicide attempts
• Post-traumatic stress disorder (PTSD)
BRUISES AND CONTUSIONS
• Accidental bruises NCP AND MANAGEMENT
• Birth trauma • The major nursing care planning goals for the child
• Bleeding disorder experiencing abuse includes:
• Coining o Ensuring adequate nutrition
• Cupping o Promoting the safety of the abused child
• Congenital dermal melanocytosis (Mongolian o Providing emotional support to the child
spots) and family
• Erythema multiforme o Improving parenting skills
• Hemangioma o Building parental confidence
• Hemophilia
NURSING PROBLEM PRIORITIES
BURNS The following are the nursing priorities for a child
experiencing abuse:
• Accidental burns
• Safety assessment and protection
• Atopic dermatitis
• Emotional support and trauma-informed care
• Contact dermatitis
• Collaboration with multidisciplinary team for
• Impetigo
comprehensive evaluation and intervention.
• Inflammatory skin conditions
• Sunburn NURSING ASESSMENT
Assess for the following subjective and objective data:
FRACTURES
• Child expressing:
• Accidental o Fear
• Birth trauma o Anxiety
• Congenital syphilis o Distress
• Malignancy • Child reporting:
• Osteogenesis imperfecta o Physical pain
• Osteomyelitis o Injuries
• Rickets o Discomfort
• Child expressing feelings of:
SCURVY o Worthlessness
• Toddler’s fracture o Guilt
o Shame

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NCM 117
ABUSE AND VIOLENCE
SABIO
• Child disclosing incidents of abuse to a trusted
adult or healthcare professional
• Signs of physical injuries such as:
o Bruises
o Burns
o Fractures
o Scars
• Signs of neglect such as:
o Poor hygiene
o Inadequate clothing
o Malnourishment
• Behavioral changes including:
o Aggression
o Withdrawal
o Regression
• Delayed developmental milestones
• Evidence of sexual abuse such as:
o Difficulty walking or sitting
o Genital injuries
o STI
• Poor academic performance or attendance
• Caregiver behavior that is inconsistent, neglectful,
or abusive.
• Reports or documentation of abuse from:
o School personnel
o Neighbors
o Social services
NURSING DX
• Following a thorough assessment, a nursing
diagnosis is formulated to specifically address the
challenges associated with child abuse based on
the nurse’s clinical judgment and understanding of
the patient’s unique health condition.
• While nursing diagnoses serve as a framework for
organizing care, their usefulness may vary in
different clinical situations.
• In real-life clinical settings, it is important to note
that the use of specific nursing diagnostic labels
may not be as prominent or commonly utilized as
other components of the care plan.
• It is ultimately the nurse’s clinical expertise and
judgment that shape the care plan to meet the
unique needs of each patient, prioritizing their
health concerns and priorities.
NURSING GOALS
Goals and expected outcomes may include:
• The child will manifest no further weight loss, and
if malnourished, will gain 2.2 lb (1kg) per week.
• The child will:
o Make eye contact
o Has relaxed facial features
o Reports decreased anxiety if age-
appropriate
• The parent will demonstrate appropriate parenting
behaviors.
• The parent will provide a safe environment for the
child.
• The parent will establish a positive relationship
with the child and realistic expectations for self and
the child.
• The child will not experience maltreatment or
abuse by parents or other offenders.
NURSING INTERVENTIUONS AND ACTIONS
Therapeutic interventions and nursing actions for a child
experiencing abuse may include:
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IMPROVING NUTRITIONAL STATUS
• Child abuse can lead to malnutrition in patients
due to:
o Neglect
o Inadequate food intake
o Limited access to food
• These factors can have serious long-term effects
on the child’s health and development,
emphasizing the need for appropriate nursing care
plans.
• Assess for signs and symptoms of malnutrition:
o A child with nutritional deficiency
manifests:
§ Decreased attention span
§ Confused
§ Pale and dry skin
§ Subcutaneous tissue loss
§ Dull and brittle hair
§ Red, swollen tongue and
mucus membranes
o Assess and record the amount,
consistency, and color of stools and
emesis.
o Provide a guide on the absorption of
nutrients in the body.
o Monitor I&O and food intake
§ Weigh client daily
§ Allows the evaluation of the
number of calories being
consumed per day and the
progress of nutritional therapy.
o Maintain a good oral hygiene prior to
meals.
§ Promotes good appetite and
enhances the taste of
food/fluids.
o Encourage patients to assist the child
during feeding.
o Eating as a self-care activity enhances
self-esteem.
o Encourage small, frequent feedings high
in carbohydrates and protein.
§ Small meals decrease fatigue
and are easier to tolerate.
o Encourage adequate rest periods.
§ Minimizes and improves the
child’s appetite.
• Consider the possible need for enteral or
parenteral nutritional support as indicated.
• Nutritional support may be recommended for those
who are unable to maintain nutritional intake by
the oral route.
• Consult and refer to a dietitian or nutritional
support team for dietary counseling.
• A dietitian or nutritional team can individualize the
child’s diet within prescribed restrictions.
REDUCING ANXIETY
• Anxiety can be a common response for children
experiencing abuse, as they may feel constant
fear, hypervigilance, and insecurity in their
environment.
• Ineffective parenting in the context of child abuse
can exacerbate the child’s anxiety, as they may not
receive the necessary emotional support,
consistent care, or protection from further harm,
leaving them feeling overwhelmed and helpless in
coping with their traumatic experiences.
NCM 117
ABUSE AND VIOLENCE
SABIO
• Assess the level of anxiety and fear in the child
an how it is manifested;
• Determine the source of anxiety and note
reactions to staff and parents at each contact.
o Provides information about the source
and level of anxiety and what might
relieve it and the basis to judge the
improvement.
• Encourage the expression of concerns and
fears of the child regarding the environment;
• Grant questions and provide honest
explanations and communication at the level of
the child’s age.
o Provides an opportunity to release
feelings that can decrease anxiety.
• Demonstrate affection and acceptance of the
child even if not returned or ignored;
• Avoid reinforcing negative behavior.
o Promotes trust of staff and positive
behavior of the child.
• Provide consistent staffing for the child,
preferably those who seem to relate to the
child
o Promotes familiarity and trusting
relationships with staff.
• Provide a play program with other children;
• Set aside time to be aloe with the child or quiet
time for the child as well;
• Praise the child or reward with a special treat
when appropriate.
o Modifies negative behavior by promoting
interactions with others and rewarding
desired behaviors.
o Promotes self-esteem.
• Provide treatment of injuries;
• Avoid treating the child as a victim, asking too
many questions, or forcing any discussion.
o Prevents increased anxiety and stress in
the child by discussion of abuse.
• Explain all treatments and procedures to be
done and their purpose and that someone will
accompany them to a different department if
needed.
o Provides preparation and information
that will assist in preventing fear or
anxiety.
• Refer for counseling services for the child as
indicated.
o Reduces anxiety and supports the child
in dealing with abuse and negative
behavior.
• Assess parents for the achievement of
developmental tasks of self and understanding
of child’s growth and development;
• How they are bonded and attached to the child;
• How they interpret and respond to the child;
• How they accept and support the child;
• How the meet the child’s social, psychological,
and physical needs.
o Provides information about parent-child
relationships and parenting styles that
may lead to child abuse.
o Identifies parents at risk for violence or
other abusive behavior.
• Provide an opportunity for parents to express
their feelings, personal needs, and goals;
• Avoid making judgmental remarks or
comparing the parents to other parents.
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o Supports parents in meeting their own
needs.
• Praise parents for their participation in the
child’s care, and tell the parents that they are
giving good care to the child.
o Reinforces positive parenting behaviors
and increases a feeling of adequacy.
• Provide a child-nurturing role model for
parents to emulate.
o Promotes the development of parenting
skills by imitation.
• Include parents in planning care and setting
goals.
o Promotes participation of parents in
meeting the child’s needs.
• Discuss with parents’ methods to reduce
conflict, to be consistent in the approach to the
child’s behavior and needs, and to avoid siding
with the child over the parents.
o Promotes a more positive child-parent
relationship.
• Teach parents developmental tasks for child
and parents;
• Difference in developmental level between
child and parents, and appropriate tasks for
age levels.
o Provides information that assists parents
in responding realistically and
appropriately to child’s needs at different
age levels.
• Instruct parents to maintain their own health
by getting adequate rest, nutrition, and
exercise; and to participate in leisure activities
and make social contacts.
o Provides information on the importance
of parents meeting their own needs to
enable them to better care for and cope
with their children.
• Refer to community agencies that offer
parenting classes and support groups.
o Provides education in parenting skills.
• Initiate referrals to social services, parenting
classes, or counseling as appropriate;
• Inform parents that child protection services
have been contacted to investigate the child’s
health status and safety;
• Keep the parents informed of the child’s health
status (unless or until custody of the child is
removed from parents)
o Provides options if parenting is
unsatisfactory or inadequate.
PREVENTING TRAUMA
• Patients with child abuse are at risk for trauma due
to the physical, emotional, and psychological harm
inflicted upon them by the abuser.
• The traumatic experience can have long-term
effects on the child’s mental health and well-being
leading to symptoms such as:
o Anxiety
o Depression
o PTSD
o Difficulty forming relationships in the
future.
• Assess the abuser for violent behavior or other
abusive patterns, use of alcohol or drugs, or
other psychosocial problems.
o Provides information to determine
warning signs of child abuse.
NCM 117
ABUSE AND VIOLENCE
SABIO

• Assess the behavior of parents towards the

child, including:
o Responses to the child’s behavior
o Ability to comfort the child
o Feelings
o Perceptions towards the child
o Expectations for the child
o Over-protective or concern for the
child
§ Reveals characteristics that
may indicate risk for abuse.
• Maintain factual and objective documentation
of all observations, including:
o Child’s physical condition
o Child’s behavioral response to
parents, healthcare workers, and
other visitors
o The parent’s response to the child
o Interviews with family members
§ Provides information that may
be used in legal action
regarding abuse.
• Communicate information and needs of the
child to those on the abuse team. (or to new
caretakers if the child is being placed with a foster
parent or someone other than parents);
• Provide written instruction for care and the
child’s needs
o Provides care plan for the child based
on the court decision to caretakers
working with the family based on the
court’s decision for the child’s care.
• Instruct parents in identifying events that lead
to child abuse and in methods to deal with
behavior without harming the child.
o Prevents further abusive behavior
directed at the child.
• Inform parents to follow-up care and needs of
the child, need to evaluate the child’s progress
o Promotes emphasis on child care and
prevention of recurrence of abuse.
• Inform parents of the child’s placement in a
foster home, and allow parents to meet and
speak to a new caretaker.
o Prepares parents for a court order of
alternate placement to ensure a safe
environment.
• Inform Parents Anonymous and other child
protective groups to contact for assistance.
o Provides self-help group activities,
information, and support based on the
type of abuse and parental needs.
• Initiate referral to a social worker, public health
nurse, or psychological counselor before
discharge to the home.
o Provides support to child and family, and
monitors behaviors following discharge.

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