Persons at Risk for Abuse or Violence - Chapter 24

Child, Older Adult, and Intimate Partner Abuse Chapter 26 Nursing 204West Coast UniversityViolence of rape is a national health problem that confront nursed in many different clinical settings. Victims are seen not only in psychiatric units but also in the community setting, in pediatric units, intensive care units, medical-surgical units, maternal care setting, in ambulatory setting, and geriatric units.1Types of AbusePhysical abuseSexual abuseEmotional abuseNeglectEconomic abuse

People at Risk for ViolenceSexual abuse90+% of rape victims are womenNot age related18-20% of rape victims are teens50% of victims raped by spouse, partner, relative, or friend50% of rapes on college campuses are date rapes80+% of sexual assault involves alcoholCycle of ViolenceProcess of escalation/de-escalationTension-building stageAttempts to reduce tension by both partnersAcute battering stageHoneymoon stageTension builds and cycle continues

Epidemiologyand Comorbidity PrevalenceHalf of all Americans have experienced violence in their familiesComorbiditySecondary effects of violenceAnxietyDepressionSuicidal ideation

Actual Occurrence of Violence Requires: PerpetratorVulnerable personCrisis situation

Characteristics of PerpetratorsConsider their own needs more important than needs of othersPoor social skillsExtreme pathological jealousyMay control family financesLikely to abuse alcohol or drugs

Characteristics of Vulnerable Persons: WomenPregnancy may trigger or increase violenceViolence may escalate when wife makes move toward independenceGreatest risk for violence when attempts to leave relationship

Characteristics of Vulnerable Persons: ChildrenYounger than 3 years Perceived as differentRemind parents of someone they do not like Product of an unwanted pregnancyInterference with emotional bonding between parent and child

Characteristics of Vulnerable Persons: Older Adults Poor mental or physical healthDependent on perpetratorFemale, older than 75 years, white, living with a relativeElderly father cared for by a daughter he abused as a childElderly woman cared for by a husband who has abused her in the past

Theories of Domestic ViolenceNeurobiologic theoryRole of serotonin (5-HT), corticotropin-releasing factor (CRF)Intrapersonal theory Experience of previous abuse a strong predictor for violenceSocial learning theoryFamily models, media modelsGender bias theorySocioeconomic factors

Assessment: Interview GuidelinesVerbal approachesTell me about what happened to you.Who takes care of you? (for children and dependent elders)What happens if you do something wrong?How do you and your partner resolve disagreements?What do you do for fun?Who helps you with your children/parent?What time do you have for yourself?

Assessment: Interview GuidelinesContinuedOpen-ended questions for parentsWhat arrangements do you make when you have to leave your child alone?How do you discipline your child?When your infant cries for a long time, how do you get him/her to stop?What about your childs behavior bothers you the most?

Assessment Should include: Violence indicatorsLevel of anxietyCoping responsesFamily coping patternsSupport systemsSuicide and/or homicide potentialDrug and alcohol useNursing DiagnosesRisk for injuryRisk for violence (self- or other- directed)AnxietyFearDisabled family copingPowerlessnessCaregiver role strain

Outcomes IdentificationEvidence that the victim is no longer hurt or exploitedPhysical abuse has ceasedEmotional abuse has ceasedSexual abuse has ceasedFinancial exploitation has ceased

PlanningGuidelines developed byThe Joint Commission on Accreditation of Healthcare OrganizationsThe Nursing Network on Violence Against WomenThe general tolerance of violence in America must be addressed if long-lasting changes are to be made.

Implementation Reporting abuseCounseling safety plan Case managementMilieu managementPromotion of self-care activities Health teaching and health promotion

Prevention of AbusePrimary preventionMeasures taken to prevent the occurrence of abuseSecondary preventionEarly intervention in abusive situations to minimize their disabling or long-term effectsTertiary preventionFacilitating healing and rehabilitative processProviding supportAssisting survivors of violence to achieve their optimal level of safety, health, and well-beingSexual Assault

Chapter 27Sexual AssaultAny type of sexual activity the victim does not want or agree toFrom inappropriate touching to penetrationVerbal sexual assault can occur by phone or electronically onlineForced activities Prostitution or posing for pornographic pictures or videosChildren, older adults, women, or men can be victims

RapeType of sexual assaultNonconsensual vaginal, anal, or oral penetration, obtained by force or by threat of bodily harm or when a person is incapable of giving consentSecond most violent crime (FBI, 2008)

Epidemiology People of lower socioeconomic classes more often victims80% of victims are white1/3 of all assaults occur inside homeMost of time, no weapon involvedYoung females (1219) at particular risk9% to 10% of all rapes are male victim

Profile of Sexual PerpetratorsYoung 30% under 2123% under 30Under the influence of alcohol or drugs at time of offense61% acquainted with victim

Psychological Effects of Sexual Assault DepressionSuicideAnxietyFearDifficulties with daily functioningLow self-esteemSexual dysfunctionSomatic complaintsResponses to RapeA variety of factors contribute to the response.Depersonalization, denial are common defense mechanismsAnxiety, agitation, nonpurposeful behaviors, shock, disbelief, fear are common emotional responsesThe victim usually experiences extensive physical injuries.

Long-term ConsequencesPost-trauma depression which may develop into a major depressive disorderDisruption in daily functioningFlashbacks, violent dreams, preoccupation with thoughts of future dangerSocial withdrawal, concerns about safetySexual problemsHistory of Sexual Abuse in Psychiatric Patients Associated with a Characteristic PatternDepressionAnxiety disordersChemical dependencySuicide attemptsSelf-mutilationCompulsive sexual behaviorPsychosis-like symptoms

Rape-Trauma Syndrome: Acute PhaseOccurs immediately after the assaultMay last for a few weeksLifestyle disorganizedSomatic symptoms are commonReaction to crisis includes disruptions in cognitive, affective, and behavioral functions

Rape-Trauma Syndrome: Long-Term Reorganization PhaseReactions likely to be experiencedinclude:Intrusive thoughtsIncreased motor activityIncreased emotional labilityFears and phobias

Theories of Sexual AbuseIntrapersonal TheoryGuidelines for perpetrator assessment:Low self-esteem Emotionally deprived as childrenLack impulse controlRigid, overcontrolling, aggressiveFamily Systems TheoryFamily system may be enmeshed, chaotic, with poor communication patternsNursing ProcessPhysical AssessmentBehavioral AssessmentAffective AssessmentCognitive AssessmentSociocultural AssessmentAssessmentFollow protocols of hospital regarding rape victims.Assess:Level of anxietyCoping mechanismsAvailable support systemsSigns and symptoms of: Emotional traumaPhysical trauma

Nursing DiagnosisRape-trauma syndrome

Ineffective copingOutcomes IdentificationAbuse protectionAbuse recovery: emotionalAbuse recovery: sexual CopingPersonal resiliencySexual functioningStress level InterventionsIndividual-Based:Assure safety, develop rapport, clarify presenting problems, identify victims strengths, abilities, coping skills, identify available support systems, suggest group therapy, experience anger, work through their terrifying fearsCommunity-Based:Identify risk factors, implement crisis interventionsInterventionsCounseling24-hour telephone hotlineEmergency departmentNonjudgmental careEmotional supportConfidentialityListen and let survivor talk

InterventionsContinuedPromotion of self-care activities Provide detailed written information concerning referral and follow-up options

Case management After initial evaluation: Provide follow-up assessment within 24 to 48 hoursProvide follow-up visits at 2, 4, and 6 weeks

Treatment of Families Experiencing ViolenceMultidisciplinary ApproachAssess physical safety first for both victim and abuserPsychoeducationFocus on communication, anger managementEmpowering the VictimAddress self-esteem, anxiety, depressionTreating the AbuserViolence is a choiceTreatment EvaluationShort-term:Identification of domestic violenceFamilys ability to recognize the problemFamilys willingness to accept assistanceRemoval of the victim from the situation Long-term:Primary prevention Secondary prevention Spirituality Questions and strugglesConnectednessTrusting relationshipsSelf-forgivenessHealingRoles of the NurseNurses are involved in: Individual interventions for the victimFamily assessment, and family therapyCommunity awareness and educationPrevention and public policy changes

Self-AwarenessBe aware of personal beliefs and feelings about rape.Prepare to give empathetic and effective care.Examine personal feelings about abortion.