1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 12 Abuse and Violence

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Picture of Abuse and Violence Abuse: wrongful use, maltreatment of another –Perpetrator typically someone the person knows Victims across lifespan: spouses, partners, children, elders Evidence of physical injuries requiring medical attention Psychological injuries with broad range of responses

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of Violent Families Family violence: spouse battering, neglect and physical, emotional, or sexual abuse of children, elder abuse, marital rape Common characteristics regardless of type of abuse (see Box 12.1) –Social isolation –Abuse of power, control –Alcohol, other drug abuse –Intergenerational transmission process

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations Domestic violence spanning families of all ages and from all ethnic, racial, religious, socioeconomic, sexual orientation backgrounds Battered immigrant women at particular risk –Facing increased legal, social, economic barriers

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence Mistreatment or misuse of one person by another in context of emotionally intimate relationship Emotional or psychological: name-calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak to or ignoring victim

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Physical: shoving, pushing, battering, choking Sexual: assaults during sexual relations, rape Combination (common) Victims: primarily women (increased rates during pregnancy)

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Prevalence in same-sex relationships as in heterosexual relationships; victims with fewer protections Often perpetrated by husband against wife

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Clinical picture –Abuser’s view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem-solving and social skills –Increasing violence, abuse with any signs of independence –Victim commonly dependent; viewed as unable to function without husband

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Cycle of abuse and violence –Violent episode → honeymoon phase → tension- building → violent episode

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Identification important; victims commonly not seeking direct help for problems Screening/assessment: SAFE (see Box 12.2) –Stress/safety –Afraid/abused –Friends/family –Emergency plan Appropriate techniques (see Table 12.1)

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The honeymoon phase of violence often occurs before the first episode of violence.

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: The honeymoon phase occurs after an episode of violence in which the abuser expresses regret, and then apologizes and promises it will never happen again.

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intimate Partner Violence (cont.) Treatment and interventions –Laws related to domestic violence; arrest –Restraining order/civil orders of protection –Shelters –Individual psychotherapy/counseling, group therapy, support and self-help groups –Treatment for anxiety/depression

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Child Abuse Intentional injury of a child –Physical abuse or injuries –Neglect or failure to prevent harm –Failure to provide adequate physical or emotional care or supervision –Abandonment –Sexual assault or intrusion –Overt torture or maiming

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Child Abuse (cont.) Clinical picture of parents –Minimal parenting knowledge, skills –Emotionally immature, needy, incapable of meeting own needs –View children as property –Cycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children)

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Child Abuse (cont.) Identification important (see Box 12.3) Report suspected child abuse Treatment and intervention –Child safety, well-being a priority –Psychiatric evaluation/possible long-term therapy/play therapy (for very young child) –Family therapy if reuniting feasible –Psychiatric or substance abuse for parents –Foster care (short or long term)

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Abuse Maltreatment of older adults –Physical, sexual, psychological abuse, or neglect –Self-neglect –Financial exploitation –Denial of adequate medical treatment 60% perpetrators spouses, 20% adult children, 20% others

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Abuse (cont.) People who abuse elders almost always in caretaker role or elders depend on them in some way Elders often reluctant to report abuse due to fear of alternative (nursing home) Clinical picture: variable depending on type of abuse

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Abuse (cont.) Assessment (potential indicators, see Box 12.4) Treatment and intervention –Caregiver stress relief –Additional resources –Possible removal of elder or caregiver

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Adults who were abused as children are more likely to abuse their own children.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: The tendency for adults to raise children in the same way they were raised perpetrates the cycle of family violence. Adults who were victims of abuse as children frequently abuse their own children.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault Crime of violence, humiliation of victim expressed through sexual means Perpetration of act of sexual intercourse with female against her will and without consent –Whether will is overcome by force, fear of force, drugs, or intoxicants

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Also considered rape if woman incapable of exercising rational judgment because of mental deficiency or when younger than age of consent –Only slight penetration of vulva needed (full erection/ejaculation not necessary)

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Strangers (approximately 26% of rapes), acquaintances, married people, people of same sex Date rape (acquaintance rape) Highly underreported crime Most commonly occurring in woman’s neighborhood, often inside or near home

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Most rapes premeditated Male rape significantly underreported Alcohol frequently involved (34% of cases)

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Four categories of male rapists –Power assertive rapist (30%) –Power reassurance or opportunity rapist (30%) –Anger retaliation rapist (24%) –Anger excitement or sadistic rapist (16%)

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Feminist theory: women historically objects for aggression Severe physical, psychological trauma –Medical problems

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Severe physical, psychological trauma (cont.) –Psychological problems Fear, helplessness, shock, disbelief, guilt, humiliation, embarrassment Avoidance of places or circumstances of rape; loss of previously pleasurable activities Depression, anxiety, PTSD, sexual dysfunction, insomnia, impaired memory, suicidal thoughts Myths, misunderstandings (see Box 12.5)

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rape and Sexual Assault (cont.) Assessment: –Physical examination; preservation of evidence (rape kit/rape protocol) –Description of what happened Treatment and intervention –Immediate support –Education (see Box 12.6) –Prophylactic treatment of STIs, pregnancy –Therapy to restore victim’s sense of control

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community Violence School violence (homicides, suicides, theft, violent crimes) Bullying (correlated with an increase in suicides) Hazing Effects on children, young adults Violence on larger scale (i.e., terrorism) Early intervention, treatment for victims

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about rape is most accurate? –A. It is a highly reported crime. –B. Most rapes are premeditated. –C. Rape requires ejaculation. –D. Provocative dress invites rape.

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Most rapes are premeditated. Rationale: Most rapes are premeditated. –Rape, an underreported crime, requires only slight penetration of the vulva. Full erection or ejaculation is not necessary. Provocative dress leading to rape is a myth.

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Assessment Sensorium, intellectual processes –Disorientation (during flashbacks), memory gaps Judgment, insight –Impaired decision-making, problem-solving abilities Self-concept –Low self-esteem

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Assessment (cont.) Roles, relationships –Problems with relationships, work, authority figures Physiologic considerations –Difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Assessment (cont.) History of trauma or abuse General appearance, motor behavior –Hyperalertness, anxiety, agitation Mood, affect –Wide-ranging emotions from passivity to anger Thought processes, content –Nightmare, flashbacks, destructive thoughts, or impulses

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Data Analysis Common nursing diagnoses –Risk for self-mutilation –Ineffective coping –Posttrauma response –Chronic low self-esteem –Powerlessness

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Outcome Identification The patient will –Be physically safe –Distinguish between self-harm ideas and taking action on those ideas –Learn healthy ways to deal with stress –Express emotions nondestructively –Establish social support network in community

38. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Intervention Promoting patient’s safety Helping patient cope with stress, emotions using grounding techniques Helping promote patient’s self-esteem Establishing social support

39. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Nursing Process: Evaluation Outcomes possibly taking years to achieve –Protection of self –Ability to manage stress, emotions –Ability to function in daily life

40. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Becoming comfortable asking all women about abuse (SAFE questions) Listening to accounts of abuse from patients, families Recognizing patient’s strengths, not just problems Working with perpetrators of abuse; dealing with own feelings about abuse, violence