Abuse and Violence NCLEX Review

- The Cycle of Violence

I. FAMILY VIOLENCE

• Violence begins with threats or verbal or physical minor assaults (tension building), and the victim attempts to comply with the requests of the abuser
• The abuser loses control and becomes destructive and harmful (acute battering), while the victim attempts to protect himself or herself.
• After the battering, the abuser becomes loving and attempts to make peace (calmness and diffusion of tension).
• The abuser justifies that violence is normal and the victim is responsible for the abuse. - Outsiders are usually unaware of what is happening in the family.
• Family members are isolated socially and lack autonomy and trust among each other; caring and intimacy in the family are absent.
• Family members expect other members of the family to meet their needs, but none are able to do so. - The abuser threatens to abandon the family.

A. Types of violence

• Physical Violence - Infliction of physical pain or bodily harm
• Sexual Violence - Any form of sexual contact without consent
• Emotional Violence - Infliction of mental anguish
• Physical Neglect - Failure to provide health care to prevent or treat physical or emotional illnesses
• Developmental Neglect - Failure to provide physical and cognitive stimulation needed to prevent developmental deficits
• Educational Neglect - Depriving a child of education
• Economic Exploitation - Illegal or improper exploitation of money, funds, or other resources for one’s personal gain

B. The Vulnerable Person

• The vulnerable person is the one in the family unit against whom violence is perpetrated.
• The most vulnerable individuals are children and older adults.
• The perpetrator of violence and the person targeted by the violence can be male or female.
• Battering is a crime.

C. Characteristics of abusers

• Impaired self-esteem
• Strong dependency needs
• Narcissistic and suspicious
• History of abuse during childhood
• Perceive victims as their property and believe that they are entitled to abuse them

D. Characteristics of victims

• Victims feel trapped, dependent, helpless, and powerless
• Victims of abuse may become depressed as they are trapped in the abusers’ power and control cycle
• As victims’ self-esteem becomes diminished with chronic abuse, they may blame themselves for the violence and be unable to see a way out of the situation.

E. Nursing Interventions:

1. Report suspected or actual cases of child abuse or abuse of an older adult to appropriate authorities (follow state and agency guidelines).
2. Assess for evidence of physical injuries
3. Ensure privacy and confidentiality during the assessment, and provide a nonjudgmental and empathetic approach to foster trust; reassure the victim that he or she has not done anything wrong.
4. Assist the victim to develop self-protective and other problem-solving abilities.
5. Even if the victim is not ready to leave the situation, encourage the victim to develop a specific safety plan (a fast escape if the violence returns) and where to obtain help (hotlines, safe houses, and shelters); an abused person is usually reluctant to call the police.
6. Assess suicidal potential of the victim.
7. Assess the potential for homicide.
8. Assess for the use of drugs and alcohol.
9. Determine family coping patterns and support systems.
10. Provide support and assistance in coping with contacting the legal system
11. Assist in resolving family dysfunction with prescribed therapies.
12. Encourage individual therapy for the victim that promotes coping with the trauma and prevents further psychological conflict.
13. Encourage individual therapy for the abuser that focuses on preventing violent behavior and repairing relationships.
14. Encourage psychotherapy, counseling, group therapy, and support groups to assist family members to develop coping strategies.
15. Assist the family to identify an access to community and personal resources.
16. Maintain accurate and thorough medical health records.

F. Assessment Questions for Violence and Abuse

• “Has anyone ever touched you in a way that made you uncomfortable?”
• “Is anyone hurting you now?”
• “How do you and your partner deal with anger (or disagreement)?”
• “Has your partner ever hit you?”
• “Have you ever been threatened by _____”
• “Does your partner prevent you from seeing family or friends” “Does your partner ever use the children to manipulate you?” “Did (or does) anyone in your family deal with anger by hitting?”
• “Who do you play with most often? Is there anyone you do not like playing with? Are there games you don’t like playing?”

II. CHILD ABUSE

- involves physical, emotional, or sexual abuse and neglect

A. Assessment

1. Physical abuse
   • Unexplained bruises, burns, or fractures
   • Bald spots on the scalp
   • Apprehensiveness in the child
   • Extreme aggressiveness or withdrawal
   • Fear of parents
   • Lack of crying when approached by a stranger 
2. Physical neglect
   • Inadequate weight gain
   • Poor hygiene
   • Consistent hunger (begs or steals food)
   • Inconsistent school attendance
   • Constant fatigue
   • Reports of lack of child supervision
   • Delinquency
3. Emotional abuse
   • Speech disorders
   • Habit disorders, such as sucking, biting, rocking
   • Learning disorders
   • Self-harm behaviors
4. Sexual abuse
   • Difficulty walking or sitting
   • Torn, stained, or bloody underclothing
   • Pain, swelling, or itching of the genitals
   • Bruises, bleeding, or lacerations in the genital or anal area
   • Poor peer relations
   • Delinquency
   • Changes in sleep patterns
   • Self-harm behaviors
5. Shaken baby syndrome
   • Abuse can cause intracranial hemorrhage, leading to cerebral edema and death.
   • The infant often has respiratory problems.
   • The nurse would note full bulging fontanels and a head circumference greater than expected

B. Nursing Interventions:

1. Assess injuries; support the child during a thorough physical assessment.
2. The child is likely to be removed from the abusive environment to a safe place to prevent further injury while the case is being investigated.
3. Move slowly and avoid any loud noises when near the child.
4. Communicate with the child at the child’s eye level.
5. Reassure the child that he or she is not “bad” and is not responsible for the abuser’s behavior.
6. Document accurately and completely all information related to the suspected abuse.
7. When working with parents in follow-up care or counseling, assist the parents in identifying stressors and alternative ways to express feelings.
8. Provide education to the parents, and refer parents to crisis hotlines and community support systems such as Parents Anonymous (a group for parents who have been abused or fear that they may abuse their child physically) or Parents United International (a group devoted to helping sexually abused families).

 

NOTE: Report cases of suspected abuse of a child or older adult to appropriate authorities (follow state and agency guidelines); reporting is mandated by federal law.

 

III.        ABUSE OF THE OLDER ADULT

• involves physical, emotional, or sexual abuse; neglect; and economic exploitation.
• Older adults at most risk include individuals who are dependent because of illness, immobility, or altered mental status.
• Factors that contribute to abuse and neglect include long-standing family violence, caregiver stress, and the older adult’s increasing dependence on others.
• Victims may attempt to dismiss injuries as accidental, and abusers may prevent victims from receiving proper medical care to avoid discovery.
• Victims often are isolated socially by their abusers.

A. Assessment

1. Physical abuse
   • Sprains, dislocations, or fractures
   • Abrasions, bruises, or lacerations
   • Pressure sores
   • Puncture wounds
   • Burns
   • Skin tears
2. Sexual abuse
   • Torn or stained underclothing
   • Discomfort or bleeding in the genital area
   • Difficulty in walking or sitting
   • Unexplained genital infections or disease
3. Emotional abuse
   • Confusion
   • Fearful and agitated
   • Changes in appetite and weight
   • Withdrawn and loss of interest in self and social activities
4. Neglect
   • Disheveled appearance
   • Dressed inadequately or inappropriately
   • Dehydration and malnutrition
   • Lacking physical needs, such as glasses, hearing aids, and dentures

1. Signs of medication overdose 6. Economic exploitation
   • Inability to pay bills and fearful when discussing finances
   • Confused, inaccurate, or no knowledge of finances

B. Nursing Interventions

• Assess for physical injuries and treat physical injuries.
• Report cases of suspected abuse to appropriate authorities (follow state and agency guidelines).
• Separate the older adult from the abusive environment, if possible, and contact adult protective services for assistance in placement while the abuse is being investigated.
• Explore alternative living arrangements that are least restrictive and disruptive to the victim.
• The older adult who has been abused may need assistance for financial or legal matters.
• Provide referrals to emergency community resources.
• When working with caregivers, assess the need for respite care or counseling if needed to deal with caregiver stress

C. PRIORITY NURSING ACTIONS

Actions to Take When an Older Client is Physically Abused

1. Assess and treat the wounds.
2. Remove the victim from immediate danger.
3. Adhere to mandatory abuse reporting laws.
4. Notify the caseworker of the family situation.
5. Document the occurrence, findings, actions taken, and the victim’s response.

IV. Rape and Sexual Assault

• engaging another person in a sexual act or sexual intercourse through the use of force and without the consent of the sexual partner.
• The victim is not required by law to report the rape or assault.
• Often, the victim is blamed by others and receives no support from significant others.

Acquaintance rape: involves someone known to the victim.

Statutory rape: is the act of sexual intercourse with a person younger than the age of legal consent, even if the minor consents.

Marital rape: The belief that marriage bestows rights to sex whenever wanted and without consent of the partner contributes to the occurrence of marital rape.

• • Victims of marital rape describe being forced to perform acts they did not wish to perform and being physically abused during sex.

A. Assessment

• • • Female client
      • Obtain the date of the last menstrual period.
      • Determine the form of birth control used and the last act of intercourse before rape.
      • Determine the duration of intercourse, orifices violated, and whether penile penetration occurred.
      • Determine whether a condom was used by the perpetrator.
    • Shame, embarrassment, and humiliation
    • Anger and revenge
    • Afraid to tell others because of fear of not being believed

B. Males may be sexually abused as children and as adults and are the usual targeted victim of pedophiles; males may have more difficulty with disclosing their abuse.

 

C. Rape trauma syndrome

• • • Sleep disturbances, nightmares
    • Loss of appetite
    • Fears, anxiety, phobias, suspicion
    • Decrease in activities and motivation
    • Disruptions in relationships with partner, family, friends
    • Self-blame, guilt, shame
    • Lowered self-esteem, feelings of worthlessness
    • Somatic complaints

D. Nursing Interventions

1. 1. 1. Perform the assessment in a quiet, private area.
      2. Stay with the victim.
      3. Assess the victim’s stress level before performing treatments and procedures.
      4. Victim should not shower, bathe, douche (female), or change clothing until an examination is performed.
      5. Obtain written consent for the examination, photographs, laboratory tests, release of information, and laboratory samples.
      6. Assist with the female pelvic examination and obtain specimens to detect semen (the pelvic examination may trigger a flashback of the attack); a shower and fresh clothing should be made available to the client after the examination.
      7. Preserve any evidence.
      8. Treat physical injuries and provide client safety. i. Document all events in the care of the victim.
      9. Reinforce to the victim that surviving the assault is most important; if the victim survived the rape, he or she did exactly what was necessary to stay alive.
      10. Refer the victim to crisis intervention and support groups.