ABUSE AND VIOLENCE

Definition of Terms: 1. ABUSE Abuse is the wrongful use and maltreatment of another person Victims of abuse and trauma can have both physical and psychological injuries, including: Agitation anxiety, silence Suppressed anger or resentment Shame and guilt Feelings of being degraded or dehumanized; low self-esteem Relationship problems; mistrust of authority figures 2. VIOLENCE According to NANDA: a) Risk for other directed violence b) Risk for Self-directed violence 3. Perpetrator of violence 4.Victim of violence Kinds of Violence: 1. Bullying-an attempt by one person to hurt/frighten other people whom the bully perceives as smaller or weaker 2. Fighting- taking part in a physical struggle 3. Assault- physical attack that occurs because one person wants to harm Another person 4. Homicide- accidental or intentional killing of another person 5. Suicide- intentional taking of ones own life 6. Sexual harassment- unwanted sexual behaviors 7. Rape 8. Child abuse Neglect- the most common type CLINICAL PICTURE OF ABUSE AND VIOLENCE VICTIMS Certainly can have physical injuries Experience psychological injuries with a broad range of responses Some clients are agitated ad visibly upset Withdrawn and aloof Appearing numb or oblivious to their surroundings Violence remains undisclosed for months or even years because victims fear their abusers Victims usually suppress their anger and resentment ad do not tell anyone Survivors of abuse often suffer in silence and continue to feel guilt ad shame e.g. Children believe that somehow they are at fault and did something to deserve or provoke the abuse As adults- usually feel guilt or shame for not trying to stop the abuse

 Survivors feel degraded, humiliated and dehumanized Self-esteem is very low, view themselves as unlovable Victims ad survivors of abuse may have problems relating to others In relationships, their emotional reactions are likely to erratic, intense and perceived as unpredictable Intimate relationships may trigger extreme emotional responses Even when survivors of abuse desire closeness with another person, they may perceive actual closeness as intrusive and threatening FAMILY VIOLENCE Encompasses spouse battering Neglect and physical, emotional or sexual abuse of children; elder abuse and marital rape In may cases, family members tolerate abusive and violet behavior from relatives they would never accept from strangers In violet families, the HOME may be the most dangerous place for victims. Characteristics of Family Violence 1. Social Isolation Members of these family keep to themselves and usually do not invite others into the home or tell them what is happening 2. Abuse of Power and Control Abusive family member-holds a position of power and control over the victim The abuser not only exerts physical power but also economic and social control Abuser is often the only family member who makes decision, spends money or spends time outside the home with other people The abuser belittles and blames the victim, often by using threats and emotional manipulation 3. Alcohol and Other Drug abuse Substance abuse, especially alcoholism Alcohol does not cause the person to be abusive; rather, an abusive person also is likely to use alcohol or other drugs 50-90% of men who batter their domestic partners have a history of substance abuse 4. Intergenerational Transmission Process patterns of violence are perpetuated from one generation to the next suggests that family violence is a learned pattern of behavior Statistics show that 1/3 of abusive men are likely to have come from violent families where they witnessed wife beating or were abused themselves Women who grew up inn violent homes are 50% mor3e likely to expect or accept violence in their own relationships SPOUSE AND PARTNER ABUSE

The mistreatment or misuse of one person by another in the context of an intimate relationship The abuse can be: Emotional/Psychological Physical abuse Sexual abuse Clinical Picture Abuse is often perpetrated by a husband against a wife Abusive husband often believes his wife belongs to him and becomes increasingly violet and abusive if she shows any sign of independence The abuser has strong feelings of inadequacy and low self-esteem as well as poor problem solving ad social skills The abuser is emotionally immature, needy, irrationally jealous, possessive The abuser often experiences a sense of power ad control by bullying and physically punishing the family DEPENDENCY-most commonly found trait in abused wives who stay with their husbands According to ABA Commission on Domestic Violence, 2002 -65% of women murdered by spouses or boyfriends were attempting to leave or had left the relationships

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 Cycle of Abuse and Violence

VIOLENT BEHAVIOR

PERIOD OF CONTRITION/ REMORSE (Hoeymoon period)

Tension-building phase

o Nurses may encounter abused women in ER, clinics or pediatricians office o Nurses must be skilled in asking appropriate questions about abuse. o SAFE (Stress/Safety, Afraid/Abused, Friends/Family, Emergency Plan) questions SAFE questions can be used to assess: Stress/Safety Afraid/Abused Friends/Family Emergency plan *Stress/Safety: What stress do you experience in your relationships? Do you feel safe in your relationships? Should I be concerned for your safety? *Afraid/Abused: Have there been situations in your relationships where youhave felt afraid? Has your partner ever threatened or abused you or your children? Have you ever been physically hurt or threatened by your partner? Are you in a relationship like that now? Has your partner ever forced you to engage in sexual Intercourse that you did not want? *Friends/Family: Are your friends aware that you have been hurt? Do your parents or siblings know about this abuse?

Do you think you could tell them ad would they be able to give you support? *Emergency Plan: Do you have a safe place to go and the resources you need in an emergency? If you are in danger now, would you like help in locating a shelter? Would you like to talk to a social worker/ a counselor/ me to develop an emergency plan? o Nurse can make referrals and contact appropriate health care professionals experienced in working with abused women. o Nurses should ensure and maintain clients confidentiality. 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 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 CHILD ABUSE Types of Child Abuse: 1. Physical results from unreasonably severe corporal punishment or unjustifiable punishment - intentional, deliberate assaults on children - the victim often has evidence of old injuries that the history given by parents or caregivers does not explain adequately 2. Sexual- sexual acts performed by a adult o a child younger than 18 years. e.g. incest, rape, sodomy performed directly by the person or with an object, acts of molestation, exploitation 3. Neglect-malicious or ignorant withholding of physical, emotional, or educational necessities for the childs wellbeing Refusal to seek healthcare or delaying doing so Abandonement Inadequate supervision Reckless disregard for the childs safety Failing to enroll the child in school 4. Psychological(Emotional) Abuse -verbal assaults -constant family discord characterized by fighting, yelling and chaos. - Emotional deprivation or withholding of affection, nurturing and

normal experiences that engender acceptance, love, security and self-worth -often accompanies other types of abuse (physical and sexual abuse) Clinical Picture: Parents who abuse their children often have minimal parenting knowledge and skills. They may not understand or know what their children eed or they may be angry or frustrated because they are emotionally or financially unequipped to meet those needs. Parents who abuse their children often are emotionally immature, needy and incapable of meeting their o weeds mush less those of a child. Adults who were victims of abuse as children frequently abuse their own child. ASSESSMENT: Warning Signs of Abused/Neglected Children Serious injuries Delay in seeking treatment for a significant injury Child or parent gives a history inconsistent with severity of the injury Inconsistencies or changes in the childs history during the evaluation by either the child or adult. Unusual injuries for the childs age and level of development High incidence of UTI; bruised, red, swollen genitalia, tears or bruising of rectum/vagina Evidece of old injuries not reported (scars, fx not treated, multiple bruises that parent/caregiver cannot explain adequately Treatment ad Intervention: First part of tx: to ensure Childs SAFETY and WELLBEING Relationship of trust between the therapist is crucial to help the child deal with the trauma of abuse Long term: psychiatry, social work, psychology PLAY THERAPY- the very young child can communicate best through this therapy Social services Family Therapy Psychiatric- substance abuse treatment

ELDER ABUSE It includes the following: 1. physical 2. sexual 3. psychological 4. neglect 5. self-neglect 6. financial exploitation 7. denial of adequate medical treatment

 most victims are 75 years or older; 60-65 % are women more likely when the elder has multiple chronic mental ad physical health problems and when the elder is dependent on others for food, medical care and various ADLs Elders are often reluctant to report abuse, even when they ca, because the abuse usually involves family members whom the elder wishes to protect Clinical Picture: Victims may have bruises or fractures Lack needed eyeglasses or hearing aids Denied of food, fluids, medications or maybe restrained in a bed or chair Abuser; uses the victims financial resources for his/her own pleasure while the elder cant afford food or medications

Possible Indicators of Elder Abuse 1. Physical Abuse-frequent unexplained injuries - reluctance to seek medical treatments for injuries Malnourished, dehydrated Rashes, sores, lice Smell of urine, feces, dirt Failure to keep needed medical appointments

Untreated medical condition 2. Psychological/Emotional Abuse Reluctance to talk openly Helplessness Withdrawal or depression Anger or agitation 3. Financial Abuse Inability to manage money Unusual activity in bank accounts Different signatures on checks Recent changes in will that client could not make Missing valuables 4. Self-neglect Inability to manage own finances Inability to perform activities of daily living Inadequate clothing Signs of malnutrition or dehydration Rashes and sores

Warning Indicators from Caregivers:

Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver Blaming the elder for his/her illness or limitations Defensiveness

Treatment and intervention may involve: Providing adequate support and respite for the caregivers Changing caregiving arrangements Moving the elderly person to a safe environment RAPE AND SEXUAL ASSAULT RAPE Is a crime of violence and humiliation of the victim expressed through sexual means Perpetration of a act of sexual intercourse with a female against her will and without her consent, whether her will is overcome by force, fear of force, drugs and intoxicants It is also considered rape if the woman is incapable of exercising rational judgment because of metal deficiency The crime of rape requires only slight penetration of the outer vulva DYAMICS OF RAPE Recent research has categorized male rapists into 4 categories: 1. sexual sadists who are aroused by the pain of their victims 2. Exploitive predators who i9mpulsively use their victims as objects for gratification 3. inadequate me who believe that no woman would voluntarily have sexual relations with them and who are obsessed with fantasies about sex 4. Men for whom rape is a displaced expression of anger and rage. Women who are raped are frequently in life-threatening situations, so their primary motivation is to stay alive Degree of submission is higher when the attacker has a weapon 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

Physical and psychological trauma to rape victims is severe: Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are concerns Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid previously pleasurable activities Relationship problems may occur Treatment and Intervention: Rape treatment centers are most helpful to the victim

 Emergency setting: o Nurse is essential in providing emotional support to the victim o The nurse should allow the woman to proceed at her own pace o It is important to give as much control back to the victim as possible: Make decisions, when possible, about whom to call, what to do next It is the womans decision bout whether or not to file charges and testify against the perpetrator The victim must sign consent before any photographs or hair and nail samples are take for future evidence. o Prophylactic treatments for STDs o Rape crisis centers, womens advocacy groups and other local resourcesprovide counselor or volunteer to be with the victim from the ER through longer term follow-up o Group therapy with other women who have been raped o Supportive therapy It often takes 1 year or more for survivors of rape to regain previous levels of functioning

PSYCHIATRIC DISORDERS R/T ABUSE AND VIOLENCE 1. PTSD 2. DISSOCIATIVE DISORDER Dissociation-subconscious defense mechanism that helps a person protects his/her emotional self from recognizing the full effects of traumatic events by allowing the mind to forget or remove itself from the painful situation or memory I. Dissociative amnesia II. Dissociative fugue III. Dissociative identity disorder IV. Depersonalization Treatment: 1. COGNITIVE and BEHAVIORAL THERAPY 2. Sample Question: The nurse working with a client during a flashback says, I know youre scared, but youre I a safe place. Do you see the bed in your room? Do you feel the chair youre sitting on? the nurse is using which of the following techniques? a. Distraction c. relaxation

b. reality orientation Answer:_________________

d. grounding

helpful to use with a client who is dissociating or experiencing flashback reminds the client that he/she is in the present and is safe the nurse ca increase the clients contact with reality and diminish dissociative experience by helping the client focus on what he/she is currently experiencing through the senses. What are you touching? Are you hearing something? Can you see me and the room were in? Do you feel your feet on the floor? Do you feel your arm on the chair? Do you feel the watch in your wrist?