Chapter 55

Nursing Care of a Family in Crisis:

Maltreatment and Violence
in the Family

Vargas, Adrian Alain

Villarante, Kevin
 Chapter 55 - Nursing Care of a Family in Crisis: Maltreatment
and Violence in the Family

01 Definition of Key Terms

CONTENTS 02 Statistical Data: Philippines and World Statistics

Nursing Process Overview: For Care of a Family that has

03 Experienced Child Maltreatment or Intimate Partner
Violence

04 Health Promotion and Risk Management

 05 Child Maltreatment

06 Sexual Maltreatment

CONTENTS
07 Rape

08 Intimate Partner Violence

01 Definition of Key Terms
01 Definition of Key Terms
abusive head trauma maltreatment
factitious disorder mandatory reporters
failure to thrive molestion
hebephile pedophile
incest permissive reporters
intimate partner violence rape trauma syndrome
learned helplessness sexual maltreatment
 Statistical Data: Philippines and World
02 Statistics

• World Statistics
• Philippine Statistics
 02 Statistical Data: Philippines and
World Statistics

WORLD STATISTICS

 Nearly 3 in 4 children - or 300 million children - aged 2–4 years regularly suffer physical punishment and/or
psychological violence at the hands of parents and caregivers.
 One in 5 women and 1 in 13 men report having been sexually abused as a child aged 0-17 years.
 120 million girls and young women under 20 years of age have suffered some form of forced sexual contact.
 Globally, it is estimated that up to 1 billion children aged 2–17 years, have experienced physical, sexual, or
emotional violence or neglect in the past year(2019).

World Health Organization 2020

 02 Statistical Data: Philippines and
World Statistics

PHILIPPINE STATISTICS

 One in four (26%) ever-married women aged 15-49 has ever experienced physical, sexual or emotional
violence by their husband or partner.
 One in five (20%) women has ever experienced emotional violence, 14 percent has ever experienced physical
violence.
 5 percent has ever experienced sexual violence by their current or most recent husband or partner.
 8 in 10 Filipino children suffer from a form of violence.
 60% of physical violence suffered by children, and 38% of psychological violence, happen in their homes.
 13.7% of the respondents aged 13 to 18 years old were sexually abused at home, while growing up.

Philippine Statistics Authority 2018,

Council for the Welfare of Children and the United Nations Children's Fund
 Nursing Process Overview: For Care of a
03 Family that has Experienced Child
Maltreatment or Intimate Partner Violence
• Assessment
• Nursing Diagnosis
• Outcome Indentification and Planning
• Implementation
• Outcome Evaluation
 03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

ASSESSMENT
Nurses are the first health care providers to identify
symptoms of possible child maltreatment or
intimate partner violence since they are the first to
take a health history, see a child or woman
undressed at a health care visit and recognize
physical signs of maltreatment and violence. They
are often the people to whom a pregnant woman or
child confides the problem.
Subjective cues:
• not allowing patient to speak or speaking in behalf of the
patient
• accompanying patient at all times.
• Nail biting, other mannerisms of stress
Objective cues:
• Head trauma
• Missing patches of hair
• Cigarette burns
• Multiple fractures in different stages of healing
• Burn on dorsal surface of hand
• Bruising (Hidden or excessive)
• Scalded feed and legs from being lowered into hot water
03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

ASSESSMENT

NOTE!!!
 If child maltreatment is suspected, talk with parents first, without the child, and then
interview the child separately to uncover inconsistencies.
 You are not investigating the concern-you are doing an initial screening to assess the need
for referral and reporting.
 The agency’s patient protective services department will do the actual inverstegation.
 03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

NURSING
DIAGNOSIS
• Pain related to burn on hand from documented
maltreatment
Nursing diagnosis associated with child • Risk for injury related to previous intimate partner
maltreatment or family violence should address violence
• Risk for other-directed violence related to admitted
both the physical and emotional results of the poor self-control
concern. • Impaired parenting related to high level of stress
• Compromised family coping as manifested by child
maltreatment related to alcohol use by father
• Disturbed self-esteem related to stalking and sexual
maltreatment
03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

OUTCOME
INDENTIFICATION &
PLANNING

 Ensure the saftey of the maltreated family member and minimize the effects of trauma.
 Report the discovery to proper authorities.
 Help the maltreated family member find a safe refuge.
 Re-establishing self esteem through a self-help or advocacy program.
 Teach empowerment, or abilty to take charge of one’s life.
 Advise to take programs of therapy to prevent future offenses.
03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

IMPLEMENTATION

PREVENTION
EDUCATION
03 Nursing Process Overview: For Care of a Family that has Experienced
Child Maltreatment or Intimate Partner Violence

OUTCOME
EVALUATION

Expected outcome should focus on specific examples of improved family interaction.

 The paren holds the baby in a caring manner and maintains goof eye contact.
 The parent attends full series of counseling sessions on learning better parenting.
 The parent states that she has the Crisis Center telephone number on her cell phone
and will call for help if she feels under threat by her partner.
 The adolescent states she can still think of herself with high self-esteem despite rape
by stepbrother.
 The parent attends monthly meetings of Parents Anonymous.
04 Health Promotion and Risk Management

• Assessment
• Nursing Diagnosis
• Outcome Indentification and Planning
• Implementation
• Outcome Evaluation
04 Health Promotion and
Risk Management
Prevention must be the goal of helathcare provider to reduce the incidence of
child maltreatment. Because many adult who maltreat children were maltreated
themselves, stoping the cycle of abuse will help prevent maltreatment in
generations to come.
04 Health Promotion and
Risk Management

1 Identify parents who may be risk for maltreating their child .

2 Be aware of parents who do not touch their infant within 24 hours, and those who make disparaging
remarks about their child’s apperance.

3 Parents may also be identified as being able to maltreat children during health maintenance visit.

4 Help parents to seek assistance from support people is another necessary step for prevention.

5 Help young parents learn about normal growth and development of children and how to better
respond to the child’s behavior.
04 Health Promotion and
Risk Management
Measure to Prevent Child Maltretment or Intimate Partner Violence
Advocate for high school or college courses
1 on parenting and growth development of
children.
5 Help parents locate support people in their
community.

2 Help children learn poblem-solving

techniques. 6 Role model caring behaviours with children
for parents.

3 Foster high sel-esteem in children and

woman. 7 Identify children who may be viewd as
special in some way by parents.

4 Help parents with resposible reproductive

palnning. 8 Identify parents who were maltreated as
children.

9 Advocate and support laws that implement the “No Hit Zone.”
 04 Health Promotion and
Risk Management
1. Does the parent have fun with the baby?
2. Does the parent establish eye contact (direct en face position) with the
baby?
3. How does the parent talk to the baby? Is every_x0002_thing expressed as a
demand?
4. Are most of the verbalizations about the child negative?
5. Does the parent remain disappointed about the child’s sex?
6. Was the child named immediately? Does the name have meaning for the
family?
7. Are the parent’s expectations for the child’s development far beyond the
child’s capabilities?
8. Is the parent very bothered by the baby’s crying?
9. Does the parent see the baby as too demanding during feedings? Does she
or he ignore the baby’s demands to be fed?
10. What is the parent’s reaction to the task of changing diapers? Is the parent
repulsed by the messiness?
11. When the baby cries, does the parent or can the parent comfort the child?
12. Are the parents receiving adequate support?
13. Is sibling rivalry a problem?
14. Is the husband jealous of the baby’s claim on the mother’s time and
affection?
15. When a parent brings the child to the physician’s offifice, does the parent
become involved and take control over the baby’s needs and what is going to
happen (during the examination and while in the waiting room)? Or does the
parent relinquish control to the physician or nurse such as undressing the
child, holding or allowing the child to express fears?
16. Can attention be focused on the child in the parent’s presence? Can the
parent see some thing positive in that focus?
17. Does the parent report nonexistent symptoms in the baby? Describe the
child in terms that you do not recognize at all? Call with strange stories, such
as the child has stopped breathing, changed color, or is doing something “on
purpose” to aggravate the parent?
18. Does the parent make emergency calls to health care providers for very
small things?
05 Child Maltreatment

• Theories of Child Maltreatment

• Reporting Suspected Child Maltreatment
• Physical Maltreatment
• Abusive Head Trauma
• Ritual Maltreatment
• Physical Neglect
• Psychological Maltreatment
• Factitious Disorder
• Failure to Thrive
05 Child Maltreatment

• Child maltreatment is the abuse and neglect that occurs to children under 18 years of
age.
• It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect,
negligence and commercial or other exploitation, which results in actual or potential
harm to the child’s health, survival, development or dignity in the context of a
relationship of responsibility, trust or power.
• Exposure to intimate partner violence is also sometimes included as a form of child
maltreatment.
05 Child Maltreatment
Theories of Child Maltreatment
Special Parent: Parents Who Maltreat
• substance abuse
• mental health issue
• young age
• low education
• low income
• single parent status
• having multiple dependent
child
• experience maltreatment
• unfamiliar with normal
growth and development of
child
• socially isolated
Special Child: Children Who are Special Circumstances: Stress
Maltreated • common house problem
• viewed as different such as blocked toilet
• less intelligent • illness in the family
• less appealing • lost a job
• unplanned child • landlord asking for rent
• did not live up to parents • rainstrom that cancels a
expectations picnic
• gender nonconfirmity
• children under 4 years
• child with disability
• mental retardation and
helath issue
• chronic illness
 05 Child Maltreatment

Reporting Suspected Child Maltreatment

Permissive Reporters Mandatory Reporters

Are encouraged to report suspected child Are professionals who are mandated by
abuse but are not required by law law to report child maltreatment

 All healthcare institutions and agencies have protocols on how the reporting of chils maltreatment should be manage.
 After and offical report, a hospital can hold the child for 72 hrs for protection.
 After 72 hrs a court proceeding will determine if the child be return to parents’ care or be kept in safer location.
 Because child maltreatment is a crime, a healthcare record can be subpeonaed and displayed in court.
 Therefore documentation is very important that it is specific and factual.
05 Child Maltreatment

Physical Maltreatment

ASSESSMENT

• Always ask caregivers to

account for any injury to a
child’s body.
• Assess injury’s proportion to
caregiver’s account.
• Ask children about the injury as
well.
NOTE!!!
• Avoid emotional involvement.
• Always assume that the parent
have done the best they could
under any circumstance.
05 Child Maltreatment

Physical Maltreatment

PHYSICAL EXAMINATION

• Head trauma
• Missing patches of hair
• Cigarette burns
• Multiple fractures in different stages
of healing
• Burn on dorsal surface of hand
• Bruising (Hidden or excessive)
• Scalded feet and legs from being
lowered into hot water
05 Child Maltreatment

Physical Maltreatment

NURSING DIAGNOSES and RELATED INTERVENTION

 Nursing Dx: Risk for injury related to documented maltreatment by parent.
 Outcome Evaluation: Child has no further physical injuries identifiable as
being inflicted by parent.
 Interventions:
1. Prevent further maltreatment
2. Provide consent care and support for the maltreate child
3. Evaulate and promote family health
05 Child Maltreatment

Abusive Head Trauma

 Abusive head trauma, previously known as shaken baby syndrome, is the

repetitive, violent shaking of a small infant by the arms or shoulders,
causing a whiplash injury to the neck, edema to the brain stem, possibly
subdural hemorrhage, and distinctive hemorrhage to the retinas.
 A contoversial diagnosis, and one difficult to prove, it is a particularly
insidious form of child maltreatment because the damage inflicted on the
infant is not readily apparent.
05 Child Maltreatment

Ritual Maltreatment

 Is a cult-based or religously, spiritually, or satanically motivated.

 Involves physical, sexual, or psychological maltreatment with bizarre or
ceremonial maltreatment.
05 Child Maltreatment

Physical Neglect

 Is a more subtle form of maltreatment than physical maltreatment.

 Can be just as damaging to a child’s welfare.
 Failing to bring a child for medical attention of failing to seek early
medical care for an infection are other signs of maltreatment.
05 Child Maltreatment

Psychological Maltreatment

 Includes constant belittling or threatening, rejecting, isolating, or

exploiting a child or is the absence of positive parenting.
 Some indicators of emotional abuse are:
 Developmental delays
 Bed-wetting without medical cause
 Frequent psychosomatic complaints
 Severe depression
 Anxiety or aggression
 Self-destructive behaviours such as self-harming
 Overly compliant child
05 Child Maltreatment

Factitious Disorder

 Formally known as Munchausen syndrome by proxy, refers to a parent

who repeatedly brings a child to a healthcare facility and reports
sysmptoms of illness when, in fact, the child is well.
 to diagnose this disorder, covert video surveillance may be necessary.
05 Child Maltreatment

Failure to Thrive

 Is a unique syndrome in which an infant falls below the 5th percentile for
weight and height on a standard growth chart or is falling in percentiles on
a growth chart.
 The nonorganic type can be considered a form of child neglect, although
this represents a very complex interplay between parent and child.
 Failure to thrive begins with subtle signs that must be taken seriously,
because it can lead to cognitive impairment in the child and even death if
allowed to continue.
 05 Child Maltreatment
Failure to Thrive
ASSESSMENT
 Take a detailed pregnancy history of children at routine
health assessment
 Always weigh child at routine assessment.
 Typical characteristics:
• Lethargy with poor muscle tone, a loss of
subcutaneous fat, or skin breakdown.
• Lack of resistance to the examiner’s manipulation,
unlike the response of the average infant.
• Rocking on all fours excessively, as if seeking
stimulation.
• Possibly a greater reluctance to reach for toys or
initiate human contact than is demonstrated by
the average infant.
• Staring hungrily at people who approach them
as if they are starved for human contact.
• Little cuddling or conforming to being held.
• Delays in sitting, pulling to a standing position,
crawling, and walking because the chil spends
so much time alone.
• Markedly delayed or absent speech because of
the lack of interaction.
 05 Child Maltreatment

Failure to Thrive

THERAPEUTIC MANAGEMENT

 Child should be remove from parents care and hospitalize for evaluation and therapy.
 Studies other than routine admission blood work and urinalysis are usually delayedto avoid submitting
such understimulated child to pain or unnecessary manipulation.
 Infants are immediately placed on a diet appropriate for their ideal weight.
05 Child Maltreatment

Failure to Thrive

 Is a unique syndrome in which an infant falls below the 5th percentile for
weight and height on a standard growth chart or is falling in percentiles on
a growth chart.
 The nonorganic type can be considered a form of child neglect, although
this represents a very complex interplay between parent and child.
 Failure to thrive begins with subtle signs that must be taken seriously,
because it can lead to cognitive impairment in the child and even death if
allowed to continue.
06 Sexual Maltreatment

• Types of Sexual Maltreatment

• Assessment
• Therapeutic Management
06 Sexual Maltreatment

 Is broadly defined as any sexual contact between a child and an

adult.
 Sexual abuse is a problem of epidemic proportions with 25%
of girls and 16% of boys in the United States sexually abused
before the age of 18 years.
 Sexual maltreatment is physically and emotionally distructive
because it leaves children unable to trust others and may result
in a sense if ambivalence toward intimacy and an overall sense
or worthlessness.
06 Sexual Maltreatment

TYPES OF SEXUAL MALTREATMENT

Sexual maltreatment involes a wide range of diagnoses from molestion to vaginal penetration.

 MOLESTION - is a vague term that includes “indecent liberties” such as oral-

genital contact, genital fondling and viewing, or masturbation

 PORNOGRAPHY and PROSTITUTION - involves photographing or describing

sexual acts by any medium involving children or distributing such material in
person or by mail, fax, cell phone, or over the Internet.

 INCEST - is a sexual activity between family members.

06 Sexual Maltreatment

ASSESSMENT
 The child reports she has had sexual activity with an adult.
 the child demostrates an awareness of sex or a sexual vocabulary beyond her
age expectations.
 The child participates in sexual expressions with dolls.
 A girl younger than 15 years of age is pregnant.
 A perineal, vaginal, or anal exam reveals inflammation or vaginal tears or anal
fissures.
 A child younger than 15 years of age has a sexually transmitted infection.
 A child has a history of symptoms of increasing anxiety such as a sleep
disturbance, development of nervous tics, nail biting, or stuttering.
 There is a change in school performance, school phobia, or truancy.
 A child reports vague abdominal pain or demonstrates acting-out behavior.
06 Sexual Maltreatment

THERAPEUTIC MANAGEMENT
 Like physical maltreatment, must be reported immediately.
 May require psycological counseling.
 Follow-up care is best done by one of the providers who sees the
child initially.
 Treatment for sexually transmitted infections or protection against
pregnancy should be provided as needed.
 Parenys may need counseling.
07 Rape

• Assessment
• Emergency Care
• Legal Considerations
07 Rape

• Is a sexual activity such as intercourse or

penetration of a body orifice by a penis or other
object under actual threatened force.
• Statutory rape- sexual activity with a person
under age of consent.
• Sexual assault- forced sexual acts.
• Is a crime of violence, not of passion.
• Both rape and sexual assault represent deviant
behavior.
• Determinig actual incident of rape is difficult.
• Victim can be on any age and gender.
07 Rape

ASSESSMENT
 RAPE TRAUMA SYNDROME- immediate physical and emotional symptoms that can last for
weeks. A form of posttruamatic stress syndrome and ussually occurs in ywo stages.
1. Disorganization phase- victim feels a combination of humiliation, shame and guilt,
embarrassment, anger and vengefulness that usually last for about 3 days.
2. Reorganization phase- may lasy for two months or years. Includes recurring nightmares,
perhaps sexual dysfunction, and continuing inability to relate to the opposite sex or to face
new surprising situations.
07 Rape

EMERGENCY CARE
5. Test to be done:
1. Large city police forceshave 6. A gynecologic and anal
 oral washing
special forces assigned to examination will be done to
 fingernail scarping
investigate rape charges. evaluate the physical condition of
 VDRL, HBsAg
2. Most healthcare agency have the victim.
 pregnancy test
Rape Trauma Team. 7. Be certaint to provide privacy.
 hair samples
3. Sexual Assualt Nurse
 vaginal smeat for sperm and
Examiner.
DNA
4. Pediatric- Sexual Assualt
 gonococcus smear
Nurse Examiner.
 vaginal washing
 skin washing
 clothing
07 Rape

LEGAL CONSIDERATIONS
 Nurses working in emergency department may be asked to testify in court about rape victim’s
appearance after the assault.
 Many victims of rape do not press charges against their assailants..
08 Intimate Partner Violence
08 Intimate Partner Violence
• is a maltreatment by a family member
againstanother adult living in the household.
• like child maltreatment, initimate partner
violence affetcs all ethnic and social groups.
• it occurs at a higher rate during pregnancy.
• maltreated women have an unintended and
unwanted pregnancy because they were
unable to fight sexual advances from their
partner.
• the reason why this appears is perplexing. but
violent family situations can be divided in
two: those in which violence preceded the
relationship or children and those in which
the violence develop after the relationship
was establish or children were born.
• in the first situation, which is more common,
the violence is brougth into the family by a
man who has history violence.
08 Intimate Partner Violence

• Cycle of Violence • pregnant maltreted women may demontrate

typical behaviours that reveals violence.
• a maltreated woman may have difficulty
following recommended pregnancy nutrition.
• a woman who has experienced recent
violence is often time anxious.
08 Intimate Partner Violence

TYPICAL LEVELS OF INTIMATE PARTNER VIOLENCE

LEVEL DESCRIPTION
1 Maltretment is occasional; consistent of slapping, punching, kicking,
verbal maltreatment. Contrusion occurs.

2 Maltreatment is becoming more frequent; beatings are sustained and

cause fractures, such as broken jaw or rib fracture.

3 Maltreatmnt is even more frequent, perhaps daily. A weapon, such

as gun, baseball bat, or broom handle, may be used. Permanent disability or death
from injuries may occur.
REVIEW
THANK YOU

Vargas, Adrian Alain

Villarante, Kevin