Anger, aggression and violence; sexual assault; Anger, Aggression, and Violence

Impact of Abuse on Survivors

}Depression }Suicidal feelings }Self-contempt }Inability to trust }Inability to develop intimate relationships }PTSD and other anxiety disorders }Low self-esteem }Substance abuse }Compulsions such as gambling, spending, promiscuity }Multiple somatic complaints }Children who witness DV: ID with an aggressor, lose respect for the victim }Phobias }Antisocial behaviors }Becoming an abuser }Criminality }Teens: running away }Physiologic consequences of long term stress: }High cortisol: risk for cardiovascular disease }Metabolic syndrome

Common Characteristics of Abusive Caregivers?

}Has behavior problems }Is financially dependent }Has marital/family conflict }Has mental/emotional difficulties }Has alcohol/substance abuse problem }Lacks understanding of the medical condition }Lacks social support }Caregiving reluctancy }Has unrealistic expectations }Caregiving inexperience }Is a blamer }Had poor past relationships } Is emotionally dependent

Characteristics of Vulnerable Persons: Older Adults What do abused older adults look like or how are they portrayed?

}Poor mental or physical health }Dependent on the perpetrator }Female, older than 75 years, white, living with a relative }Elderly father cared for by a daughter who was abused as a child }Elderly woman cared for by a husband who has abused her in the past }Older adult and adults with special needs

Feelings that may Precipitate Anger ?? (16 feeling words)

• Discounted • Embarrassed • Frightened • Found out • Guilty • Humiliated • Hurt • Ignored • Inadequate • Insecure • Unheard • Out of control of the situation • Rejected • Threatened • Tired • Vulnerable

Behavioral Indicators of Suspected Abuse, Neglect or Exploitation from the Elder

• Fear • Withdrawal • Depression • Helplessness • Resignation • Hesitation to talk openly • Implausible stories • Confusion or disorientation • Ambivalence/contradictory statements not due to mental dysfunction • Anger • Denial • Non-responsiveness • Agitation, anxiety

Abuse Protection Support: Children What do nurses need to identify, monitor, or report?

• Identify mothers who have a history of late (4 months or later) or no prenatal care. • Identify parents who have had another child removed from the home or have placed previous children with relatives for extended periods. • Identify parents with a history of domestic violence or a mother who has a history of numerous "accidental" injuries. • Determine whether a child demonstrates signs of physical abuse: -Numerous injuries in various stages of healing - Unexplained bruises and welts -Unexplained pattern, immersion, and friction burns -Facial, spiral, shaft, or multiple fractures -Unexplained facial lacerations and abrasions -Human bite marks; intracranial, subdural intraventricular, and intraocular hemorrhaging -Whiplash shaken infant syndrome -Diseases that are resistant to treatment and/or have changing signs and symptoms • Encourage admission of the child for further observation and investigation as appropriate. • Monitor parent-child interactions and record observations. • Report suspected abuse or neglect to proper authorities. ****IN children can see enuresis and defecation problems (Encopresis) that occur involuntarily

Abuse Protection Support: Older Adults

• Identify older patients who perceive themselves to be dependent on caretakers d/t -Impaired health status -Functional impairment -Limited economic resources -Depression -Substance abuse -Lack of knowledge of available resources and alternatives for care • Identify family caretakers who have a history of being abused or neglected in childhood. • Monitor patient-caretaker interactions and record observations. • Report suspected abuse or neglect to proper authorities.

Nursing Care for Special Populations: abuse and neglect across the lifespan (CHAPTER 28) Five main types of abuse

• Physical abuse is the infliction of physical pain or bodily harm such as slapping, punching, hitting, choking, pushing, restraining, biting, throwing, and burning. • Sexual abuse is any form of sexual contact or exposure without consent or in circumstances in which the victim is incapable of giving consent. Sexual abuse is also referred to as sexual assault or rape • Emotional abuse is the undermining of a person's self-worth. This may include constant criticism, humiliating, diminishing one's abilities, name-calling, intimidating, isolating, and damaging relationships with others. • Neglect is the failure to provide for physical, emotional, educational, and medical needs. • Economic abuse is controlling a person's access to economic resources making an individual financially dependent. Forbidding school attendance or employment keeps a person dependent.

Abuse Protection Support: Intimate Partners

• Screen for risk factors associated with domestic abuse: -History of domestic violence, abuse, rejection, excessive criticism, or feelings of being worthless and unloved -Difficulty trusting others or feeling disliked by others; -Feeling that asking for help is an indication of personal incompetence -High physical care needs -Intense family care responsibilities -Substance abuse -Depression -Major psychiatric illness -Social isolation -Poor relationships between domestic partners -Multiple marriages -Pregnancy -Poverty -Unemployment -Financial dependence -Homelessness -Infidelity -Divorce -Death of a loved one • Document evidence of physical or sexual abuse using standardized assessment tools and photographs. • Listen attentively to an individual who begins to talk about their own problems. • Encourage admission to a hospital for further observation and investigation, as appropriate. • Provide positive affirmation of worth. • Report any situations in which abuse is suspected in compliance with mandatory reporting laws

Exogenous Toxins that may contribute to anger, aggression, and violence

•Alcohol •Illicit Stimulants •Inhaled solvents •Amphetamines •Heavy Metals •Medications

Psychiatric Diagnoses that may contribute to anger, aggression and violence

•Antisocial Personality Disorder •Bipolar Disorder •ADHD •Conduct Disorder •Delusions •Dementia •PTSD •Paranoia •Schizophrenia •Addictions •Impulse Control Disorder

Medical Diagnoses that may contribute to anger, aggression, and violence

•Chronic Pain •Neurological Disorders •Infectious Disorders •Endocrine Disorders •Metabolic Disorders •Vitamin Deficiencies

De-escalation Techniques

•Maintain the patient's self-esteem and dignity •Maintain calmness (your own and the patients) • Assess the patient and the situation ---Safe? •Identify stressors and stress indicators •Respond as early as possible •Use a calm clear tone of voice •Use a non-threatening stance. Avoid full-frontal stance, turn a little it to the side with arms at side and palms UP. •Invest time with the patient •Remain honest with the patient •Determine what the patient considers to be needed •Identify goals WITH the patient •Avoid invading personal space; in times of high anxiety, personal space increases • Avoid arguing •Give several clear options •Use genuineness and empathy •Be assertive (not aggressive) •Do not take chances; maintain personal safety

Epidemiology •In the hospital, violence is most frequent in

•Psychiatric units •Emergency departments •Geriatric units

Aspects of an Inpatient Unit Which May Contribute to Patient's Anger

•Rules •Unfamiliar structure •When patients are not voluntary •Other patients •Contact with outside individuals •Fear

Neglect includes:

◦Failure to provide a child with food, clothing, shelter, medical care. ◦Leaving a child in a situation where the child is at risk of harm. }Neglect is a pattern of failing to provide for a child's basic needs, to the extent that the child's physical and/or psychological well-being are damaged or endangered. In child neglect, the parents or caregivers are simply choosing not to do their job. }Neglect due to poverty is not considered abuse

Destructive Effects of The Cycle of Abuse What occurs or can occur?

◦Isolation from others, withdrawal from family and friends, avoid the public ◦Low self-esteem, feelings of worthlessness ◦Depression, thoughts of suicide ◦Emotional problems, shame, emotional highs, and lows, emotional numbness ◦Illness - physically, mentally, emotionally, spiritually ◦Increased alcohol or drug use, addictions ◦Withdrawal from real life into an alternative reality - perhaps the Internet

Physical Indicators of child abuse?

◦unexplained bruises (in various stages of healing) ◦welts, human bite marks, bald spots ◦unexplained burns, especially cigarette burns or immersion burns ◦unexplained fractures, lacerations or abrasions ◦swollen areas ◦evidence of delayed or inappropriate treatment for injuries

Pharmacological Interventions

****When a patient is showing increased signs or symptoms of anxiety or agitation, it is perfectly appropriate to offer the patient an as-needed medication to alleviate symptoms. When used in conjunction with psychosocial interventions and de-escalation techniques, this can prevent an aggressive or violent incident. -During aggressive or violent incidents, haloperidol (Haldol) has historically been the most widely used first-generation antipsychotic. -SSRIs, lithium, anticonvulsants, benzodiazepines, second-generation antipsychotics, and beta-blockers are all used successfully for specific patient populations. -Anger and aggression by ADD/ADHD may be reduced through the use of psychostimulants.

Define the term: Perpetrator (in abuse)

-Applies to any member of a household who is violent toward another member such as parents, partners, siblings, and extended family members. -Perpetrators often consider their own needs to be more important than anyone else's and look toward others to meet their needs. -Both male and female perpetrators perceive themselves as having poor social skills. -They describe their relationships with their partners as being the closest they have ever known -Typically lack supportive relationships outside the relationship

Indicators of Suspected ELDER Abuse, Neglect or Exploitation from the Family/Caregiver

-Elder is not given the opportunity to speak for him or herself or to see others without the presence of the caregiver or other suspected abuser • Obvious absence of assistance, attitudes of indifference or anger toward a dependent elder • Family member or caregiver "blames" the client (e.g., accusation that incontinence is a deliberate act) • Aggressive behavior (threats, insults, harassment) • Conflicting accounts of incidents by the family, victim advocate, neighbor, victim, others • Unwillingness or reluctance to comply with service providers in planning for care and implementation • Withholding of security and/or affection • Exaggerated concern (or lack of concern) for the elder • Prematurely or inappropriately discusses marriage with the victim • Isolates elder from family/friends/social contacts

What are some Hostility-Related Variables related to anger/aggression/violence? (think external people/circumstances)

-Frustrating circumstances -Unfair application of rules -Unjust practices -Discrimination -Shaming -Humiliation

Trauma-informed care

-It is based on the notion that disruptive patients often have histories that include violence and victimization. -Traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (such as restraint) by staff -Trauma-informed care focuses on the patient's past experiences of violence or trauma and on the role these experiences currently play in their lives. In a study conducted at New York State Psychiatric Institute, patients filled out a questionnaire that identified things that made them upset, how they responded to being upset, and how they wanted to be treated when they became upset. Examples of how they wanted to be treated included talking with them and allowing them time out alone. Making use of the patients' suggestions resulted in a decreased amount of time in restraints and seclusion and a reduction in the number of fights and assaults on the unit

Health Teaching and Health Promotion: Anger & Aggression important teaching

-Model appropriate responses and ways to cope with anger -Teach patients a variety of methods to appropriately express anger -Educate patients regarding coping mechanisms, de-escalation techniques, and self-soothing skills to manage behavior. -It is also helpful to assist the patient in identifying triggers for angry or aggressive behavior. -One method that can be used if the patient is not out of control is a "do-over." ------------ The patient who responds inappropriately can try again to respond in a more appropriate way while being coached by the nurse

Patients with Marginal Coping Skills Interventions

-Moderate baseline anxiety by the provision of comfort items before they are requested (e.g., decaffeinated coffee, deck of cards). This can build rapport and acts symbolically to reassure. -Reducing ambiguity or uncertainty can also help minimize anxiety. -Assuring the patient that he or she will not go through withdrawal without medication. can be very anxiety-relieving if the patient has a chemical dependency problem -Include the use of distractions such as magazines, action comics, and video games. Generally, distractions that are colorful and do not require sustained attention work best, although this varies according to the patient's interests and abilities. - Interactions with the treatment team are predictable. This may include speaking with the physician at a specific time each day and consistency in nursing assignments. Individuals from outside the unit such as a chaplain or a volunteer may help by giving the patient more attention. -Because these patients have limited coping skills, once anxiety is moderated, nursing interventions include teaching alternative behaviors and strategies. -For patients who externalize blame, it is best to precede such teaching with a gentle challenge. The challenge serves to engage the patient's interest in teaching that might otherwise be seen as irrelevant. This intervention is also important in that the nurse has: (1) avoided a punitive or demeaning response that might have fueled escalation of the patient's anger (2) taught a number of strategies (3) provided the patient with choices and thus with more control

Planning: Anger and Aggression

-Planning interventions requires a sound assessment, including patient history (previous acts of violence, comorbid disorders, past triggers) and present coping skills. -Patients need to be willing and able to learn alternative and nonviolent ways of handling angry feelings

Environmental Factors and Staff Behavior Contributing to Anger in Clients (7)

-Rules that prevent clients from leaving activities -Power disputes over medications -Blocked access to phones, televisions, or rooms -Denials of requests in general -Physical restraint -Ignoring clients -Ordering clients to do or not to do something

Family Violence: (5 total N.D) -Signs and Symptoms?Nursing Diagnoses? -Outcomes?

1 History of abuse, history of violence, substance use Risk for violence Family members remain free of harm 2. Bruises, cuts, broken bones, lacerations, scars, burns, wounds in various phases of healing, vaginal-anal bruises, sores, discharge, peritoneal pain PainRisk for infection Timely treatment of injuries, healing of physical injuries, absence of pain, protection from further injuries 3. Restlessness, scanning, vigilance, uncertainty, isolation, fear, depression, feelings of helplessness, decreased control over environment, abuse FearPowerlessness Behavioral manifestations of anxiety absent reports a decrease in anxiety, reports feeling safe, expresses expectations of a positive future, sets goals 4. Poor eye contact and body posture, lack of respect from significant others, traumatic situation, neglect, feelings of shame and low self-esteem, feelings of worthlessness Chronic low self-esteem Maintains eye contact and erect posture, describes the positive level of confidence, expects positive responses from others, describes feelings of success and self-worth 5. Poor coping skills, hostility, impulsivity, inadequate problem solving, substance abuse Ineffective individual coping Discusses the abusive behavior, obtains needed treatment, controls impulses, refrains from substance abuse

Interventions: Anger and Aggression 1. What is nurse priority? When does intervention begin? 2. Psychosocial Interventions?

1. -Intervention begins before any sign of escalation -It is important to develop a relationship of trust with the patient by having numerous brief, nonthreatening, nondirective interactions (e.g., talking about the weather, sports, or something of interest to the patient) -Regular teaching and practice of verbal and nonverbal interventions are essential -Speak to the patient slowly and in short sentences, using a low and calm voice 2. -It is essential to acknowledge the patient's needs, regardless of whether the expressed needs are rational or possible to meet. -Clearly state your expectations for the patient's behavior: (a form of limit setting) "I expect that you will stay in control." -Patients need much more personal space. Always stay about 1 foot farther than the patient can reach with arms or legs. Be sure you have left yourself an escape route if necessary, that is, make sure that the patient is not between you and the door. -While you are giving the patient space, the patient may be invading your space with verbal abuse and profanity As uncomfortable as this may be, you cannot take the patient's words personally or respond in kind. It is also important not to end the conversation because of the patient's verbal abusiveness or to forbid the patient from communicating in this way -Use open-ended statements and questions. Find out what is behind the angry feelings and behaviors -You may want to give two options such as, "Do you want to go to your room or to the quiet room for a while?" This approach decreases the sense of powerlessness that often precipitates violence -Pay close attention to the environment Choose a quiet place to talk to the patient but one that is visible to staff. This is most beneficial in helping a patient regain control. Staff should know you are working with the patient

Risk Profile of violence r/t: Demographics? History? social/environmental? Cognitive? Behavioral?

1. Demographics •Young age •Male sex •Lack of employment •Limited education 2. History •Previous history of violence toward self or others is a strong predictor 3. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence 4. Social/Environmental Factors •Association with violent peer groups •Living environment instability •Living in a violent atmosphere •Access to lethal weapons 5 Cognitive Factors •Negative perceptions and appraisal of events 6. Behavioral Factors •Poor impulse control •Little insight •Antisocial Behaviors •Statement of intent to harm self or others •Lack of anger modulation •Coercive or manipulative interaction style

Often, others communicate anger through long-term verbal abuse. If attempts to teach alternatives have not been successful, you can use three interventions:

1. -The first is to leave the room as soon as verbal abuse begins. The patient can be informed that the nurse will return in a specific amount of time (e.g., 20 minutes) -When the situation is calmer. A matter-of-fact, neutral manner is important because fear, indignation, and arguing are gratifying to many verbally abusive patients. - If the nurse is in the middle of a procedure and cannot leave immediately, the nurse can break off conversation and eye contact, completing the procedure quickly and matter-of-factly before leaving the room. **avoid chastising, threatening, or responding punitively to the patient. 2. -Withdrawal of attention of verbal abuse is successful only if a second intervention is also used. This step requires attending positively to and thus reinforcing, non-abusive communication by the patient. Interventions can include discussing non-illness-related topics, responding to requests, and providing emotional support. 3. Patients who are verbally abusive may respond best to the predictability of routine such as scheduled contacts with the nurse (e.g., every 30 or 60 minutes). The use of such contacts provides nursing attention that is not contingent on the patient's behavior and therefore does not reinforce the abuse. Of course, the patient's illness or injury may sometimes require nursing visits for assessment or intervention outside the scheduled contact times. These visits can be carried out in a calm, brief, matter-of-fact manner. Remaining matter-of-fact with patients who habitually use anger and intimidation can be difficult; these patients are often skillful at making personal and pointed statements. It is important to remember that patients do not know their nurses personally and thus have no basis on which they can make judgments. Nurses can also vent their own responses elsewhere with other staff or family members (while maintaining confidentiality) or by critical incident debriefing.

Rape-Trauma Syndrome -What is it? -Acute phase? -Long term reorganization phase?

1. A state in which the individual experiences a sustained painful response to one or more overwhelming traumatic events that have not been assimilated Variant form of PTSD 2. Acute Phase ◦Symptoms reflect cognitive, affective, and behavioral disruptions 3. Long-term reorganization process ◦The nurse can help individual prepare for this by educating: ◦Intrusive thoughts/reexperiencing/nightmares ◦Changes in activities: moving, changing phone numbers, more frequent visits to friends, taking trips. All stem from the fear that the assailant will return ◦Increased emotional lability ◦Periods of emotional numbness ◦Fears and phobias related to elements of the rape ◦Fear of being alone ◦Fear of crowds ◦Fear of sex

Anger and Aggression 1. Define both Terms: 2. How can anger be expressed positively?

1. Anger is an emotional response to the frustration of desires, a threat to one's needs (emotional or physical), or a challenge. Aggression is an action or behavior that results in a verbal or physical attack. Aggression tends to be used synonymously with violence. --Action or behavior that results in verbal or physical attack 2. Once anger is acknowledged, channeling anger into productive pursuits such as exercise, art, or cleaning out a closet is healthy.

Considerations for Staff Safety There are six basic considerations for ensuring safety in the unit: ?

1. Avoid wearing dangling earrings, necklaces, and scarves in acute care environments. The patient may become focused on these and grab at them, causing serious injury. 2. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff needs to maintain an unobtrusive presence in case the situation escalates. 3. Always know the layout of the area. Correct placement of furniture and elimination of obstacles or hazards are important to prevent injury if the patient requires physical interventions. 4. Do not stand directly in front of the patient or in front of the doorway. The patient may consider this position as confrontational. It is better to stand off to the side and encourage the patient to have a seat. 5. If a patient's behavior begins to escalate, provide feedback: "You seem to be very upset." Such an observation allows exploration of the patient's feelings and may lead to a de-escalation of the situation. 6. Avoid confrontation with the patient, either through verbal means or through a "show of support" with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient's behavior. Security personnel is better kept in the background until they are needed to assist. 7. Debriefing WITH THE TEAM

General Assessment: Anger/Aggression 1. Signs prior to violence? 2. What are some predictors of violence? s/s? 3. Milieu characteristics of violence? 4. Why is it important to assess the patient's history of violence?

1. Signs of irritation usually are present first! ANXIETY Includes: -Increased demands -Irritability, frowning -Redness of the face -Pacing -Twisting of the hands -Clenching and unclenching of the fists. 2. Signs and symptoms •Hyperactivity: a most important predictor of imminent violence (e.g., pacing, restlessness) •Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating, and rapid pulse) •Verbal abuse: profanity, argumentativeness •Loud voice, change of pitch; or very soft voice, forcing others to strain to hear • Stone silence • Intense eye contact or avoidance of eye contact • Recent acts of violence, including property violence • Alcohol or drug intoxication • Possession of a weapon or object that may be used as a weapon (e.g., fork, knife, rock) • Isolation that is uncharacteristic 3. Milieu characteristics conducive to violence: • Overcrowding • Staff inexperience • Provocative or controlling staff • Poor limit setting • Arbitrary revocation of privileges 4 . -Assess the patient's history of aggression or violence Most of our reactions to stimuli come from our previous experiences; therefore, identifying patients' triggers is essential. Initial and ongoing assessment of the patient can reveal problems before they escalate to anger and aggression.

Personalized Safety Guide Suggestions for Increasing Safety While in the Relationship? Suggestions for Increasing Safety When the Relationship Is Over? Important Phone Numbers? Checklist of Items to Take?

1. • I will have important phone numbers available to my children and myself. • I can tell ______ and ______ about the violence and ask them to call the police if they hear suspicious noises coming from my home. • If I leave my home, I can go to (list four places) _______, _______, ______, or _______. • I can leave extra money, car keys, clothes, and copies of documents with ________. • If I leave, I will bring ________ (see checklist). • To ensure safety and independence, I will open my own savings account, rehearse my escape route with a support person, and review safety plan on ________ (date). 2. • I can change the locks; install steel or metal doors, a security system, smoke detectors, and an outside lighting system. • I will inform _______ and ________ that my partner no longer lives with me and ask them to call the police if he or she is observed near my home or my children. • I will tell people who take care of my children the names of those who have permission to pick them up. The people who have permission are ______, _______, and _______. • I can tell _______ at work about my situation and ask _______ to screen my calls. • I can avoid stores, banks, and ________ that I used when living with my battering partner. • I can obtain a protective order from ________. I can keep it on or near me at all times, as well as have a copy with ________. • If I feel down and ready to return to a potentially abusive situation, I can call _______ for support or attend workshops and support groups to gain support and strengthen my relationships with other people 3. • Police ______________ • Hotline ______________ • Friends ______________ • Shelter ______________ 4. • Identification • Birth certificates for me and my children • Social Security card • School and medical records • Money, bank books, credit cards • Keys to house, car, office • Driver's license and registration • Medications • Change of clothes • Welfare identification • Passport(s), green card, work permit • Divorce papers • Lease or rental agreement, house deed • Mortgage payment book, current unpaid bills • Insurance papers • Address book • Pictures, jewelry, items of sentimental value • Children's favorite toys and/or blankets

Assessment Guidelines - (Anger/Aggression) 5 categories/areas of assessment General risk identification includes assessing for the following:

1. A history of violence is the single best predictor of future violence. 2. Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. 3. Major factors associated with violence can be assessed with these questions: • Does the patient have a wish or intent to harm? • Does the patient have a plan? • Does the patient have the means available to carry out the plan? • Does the patient have demographic risk factors: Male gender? Aged 14 to 24 years? Low socioeconomic status? Inadequate support system? Prison time? 4. Aggression by patients occurs most often in the context of limit-setting by the nurse. 5. History of limited coping skills, including lack of assertiveness or use of intimidation, indicates a higher risk of using violence.

Assessment Guidelines Sexual Assault

1. Assess psychological trauma and document the patient's verbatim statements. 2. Assess the level of anxiety. If in a severe-to-panic level of anxiety, the patient will not be able to problem-solve or process information. Support, reassurance, and appropriate therapeutic techniques can lower the patient's anxiety and facilitate mutual goal setting and the assimilation of information. 3. Assess physical and emotional trauma. Use a preprinted body map and ask permission to take photographs. 4. Assess the available support system. Often partners or family members do not understand the trauma of rape, and they may not be the best supports to draw on at this time. 5. Identify community supports (e.g., attorneys, support groups, therapists) that work in the area of sexual assault. 6. Encourage, but not pressure, the patient to talk about the experience. 7. Assess coping skills

5 Important Steps to Communication

1.Making personal contact 2.Discovering the source of distress 3.Relieving the distress 4.Keeping everyone safe 5.Assisting with alternative behaviors and problem-solving 6. nonjudgemental observations 7. state how the observation is making you feel 8. connect with a friend

Assessment Guidelines Family Violence

Assess: 1. Signs and symptoms of victims of abuse 2. Potential for abuse in vulnerable families. For example, some indicators of vulnerable parents who might benefit from education and instruction in effective coping techniques 3. Physical, sexual, and/or emotional abuse and neglect and economic maltreatment of older adults 4. Family coping patterns- Assess family strengths as well as stressors. Questioning about memories of early family relationships can provide additional information about attitudes in the home and the way they might influence coping. Asking parents about how they were disciplined as children may provide insight into their child-rearing attitudes and practices. 5. Patient's support system- Usually in a dependent position, relying on the perpetrator for basic needs. This dependence, along with the isolation the perpetrator imposes on the person, limits the victim's access to support systems. Children's options are especially limited, as are those of the physically and mentally disabled. Assessing for support should focus on intrapersonal, interpersonal, and community resources. 6. Drug or alcohol use A person experiencing violence may self-medicate with alcohol or other drugs as a way of escaping an intolerable situation. The drugs are usually central nervous system depressants, such as benzodiazepines Assess for chronic alcohol or drug problem and provide appropriate treatment referrals. The patient should not be discharged to the abuser. Treatment choices can include both inpatient and outpatient options. 7. Suicidal or homicidal ideas Certain factors place a vulnerable person at greater risk for homicide including the following: • The presence of a gun in the home • Alcohol and drug misuse • History of violence on the part of the perpetrator in other situations • Extreme jealousy and obsessiveness on the part of the perpetrator 8. Posttrauma syndrome 9. Note lack of eye contact, hesitation, vagueness, confusion, shame, despair, powerlessness, withdrawal

Sexual Abuse Types...? (5)

Behavior involving penetration - Vaginal or anal intercourse and oral sex Fondling -Touching or kissing a child's genitals, making a child fondle an adult's genitals. Violations of privacy -Forcing a child to undress, spying on a child in the bathroom or bedroom. Exposing children to adult sexuality -Performing sexual acts in front of a child, exposing genitals, telling "dirty" stories, showing pornography to a child. Exploitation -Selling a child's services as a prostitute or a performer in pornography.

Sexual Assault - Interventions

Counseling --24-hour telephone and chat lines—such as the Rape, Abuse, and Incest National Network (RAINN)—provide direct communication with volunteers trained in rape crisis support. --provide nonjudgmental care and optimal emotional support. --Simply listening and letting the patient talk is a powerful intervention. A patient who feels listened to and understood is no longer alone and feels more in control of the situation. Promotion of Self-Care Activities -Social support is tremendously beneficial. -Printed instructions include potential physical concerns and emotional reactions, legal matters, victim compensation (state financial assistance paid through perpetrators' fines and fees), and online resources (e.g., support groups) can help. Case Management -The emotional state and other psychological needs of the patient should be reassessed by telephone or personal contact within 24 to 48 hours of discharge from the hospital. -Discuss this with the patient before discharge -Referrals should be made for resources or support services -Follow-up visits should occur at least 2, 4, and 6 weeks after the initial evaluation. -At each visit, the patient should be assessed for psychological progress, the presence of sexually transmitted diseases, and pregnancy. Follow-up examinations provide an opportunity to (1) detect new infections acquired during or after the assault; (2) complete hepatitis B vaccination, if indicated; (3) complete counseling and treatment for other STDs; and (4) monitor side effects and adherence to postexposure prophylactic medication if prescribed.

Interventions for Rape-Trauma Syndrome

Definition: Provision of emotional and physical support immediately after a reported rape Activities: • Provide support person to stay with patient. • Explain legal proceedings available to patient. • Explain rape protocol and obtain consent to proceed through protocol. • Document whether patient has showered, douched, or bathed since incident. • Document mental state, physical state (clothing, dirt, and debris), history of incident, evidence of violence, and prior gynecological history. • Determine presence of cuts, bruises, bleeding, lacerations, or other signs of physical injury. • Implement rape protocol (e.g., label and save soiled clothing, vaginal secretions, and vaginal hair combings). • Secure samples for legal evidence. • Implement crisis intervention counseling. • Offer medication to prevent pregnancy, as appropriate. • Offer prophylactic antibiotic medication against sexually transmitted disease. • Inform patient of availability of human immunodeficiency virus testing, as appropriate. • Give clear, written instructions about medication use, crisis support services, and legal support. • Refer patient to rape advocacy program. • Document according to agency policy.

Key interviewing guidelines

Do • Conduct the interview in private. • Be direct, honest, and professional. • Use language the patient understands. • Ask the patient to clarify words not understood. • Be understanding. • Be attentive. • Inform the patient if you must make a referral to Children's or Adult Protective Services, and explain the process. • Assess safety and help reduce danger (at discharge). • What happens when you do something wrong? (for children) or How do you and your partner/caregiver resolve disagreements? (for women and dependent older adults) • What do you do for fun? • Who helps you with your child(ren)/parent? • What time do you have for yourself? Questions that are open-ended and require a descriptive response can be less threatening and elicit more relevant information than questions that are direct or can be answered with yes or no: • What 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 child's behavior bothers you the most? Do Not • Try to "prove" abuse by accusations or demands. • Display horror, anger, shock, or disapproval of the perpetrator or situation. • Place blame or make judgments. • Allow the patient to feel "at fault" or "in trouble." • Probe or press for answers the patient is not willing to give. • Conduct the interview with a group of interviewers

Drugs Associated with Date Rape

GHB -pill with a salty taste -Produces relaxation, euphoria, and disinhibition Incoordination, confusion, deep sedation, and amnesia Tolerance and dependence exhibited by agitation, tachycardia, insomnia, anxiety, tremors, and sweating Rohypnol -Pill that dissolves in liquids -10 times stronger than diazepam -More potent when combined with alcohol; causes sedation, psychomotor slowing, muscle relaxation, and amnesia -Dependence and tolerance may develop Ketamine -Anesthetic frequently used in veterinary practice; also a hallucinogenic substance related to PCP (phencyclidine) -Causes dissociative reaction, with a dreamlike state leading to deep amnesia and analgesia and complete compliance of the victim -May become confused, paranoid, delirious, combative, with drooling and hallucinations

Assessment -General Assessment: reported/objective symptoms? -Interview Process and Setting?

General Assessment -Symptoms may be vague and can include chronic pain, insomnia, hyperventilation, or gynecological problems -History of sexual abuse, family violence, and drug use or abuse -Any assessment should be completed with the victim alone, and it is helpful to have an institutional policy that facilitates screening in private Interview Process and Setting -Conducting a routine assessment with tact, understanding, and a relaxed attitude -It near the patient and spend some time establishing trust and rapport before focusing on the details of the violent experience. Establishing trust is crucial if the patient is to feel comfortable enough to self-disclose. The interview should be nonthreatening and supportive. -It is better to ask about ways of solving disagreements or methods of disciplining children rather than to use the words abuse or violence. It is also important not to assume a person's sexual orientation. Use the term partner when asking about the relationship -The person who experienced the violence should be allowed to tell the story without interruption. Reassure the patient that he or she did nothing wrong. Verbal approaches may include the following: • Tell me about what happened to you. • Who takes care of you? (for children and dependent older adults)

Etiology: - Biological Factors? - Neurobiological? - Neurotransmitters? - Psychological Factors

Genetics -More of a predisposition to certain traits--may respond to life events with irritability, easy frustration, and anger. Neurobiological -Brain tumors -Alzheimer's disease -Temporal lobe epilepsy -Traumatic injury can cause anger and aggression -One area of the brain associated with aggression is the limbic system. Important structures within this system include the amygdala and hippocampus. The amygdala is the emotional center of the brain. It helps evaluate the emotional content of our experiences. It helps the brain to recognize potential threats and whether to activate the fight-or-flight response. In humans, men with lower amygdala volume exhibit higher levels of aggression from childhood to adulthood The hippocampus is essential to the formation of new memories. Aggressive behavior may result in the formation of new cells within the hippocampus. -The especially large prefrontal cortex in humans also plays an important role in aggressive behavior. responsible for executive function. Executive function allows us to distinguish between good and bad, consequences of actions, goal-directed behavior, and suppressing socially unacceptable activities Neurotransmitters Serotonin, dopamine, and GABA all play a vital role in anger and aggression. -Serotonin can both inhibit and stimulate aggressive behavior. -Dopamine's impact on reward-seeking behavior may increase aggression. Like serotonin, dopamine can sometimes enhance aggression and sometimes reduce impulsivity that leads to aggression. -GABA, the main inhibitory neurotransmitter, may reduce aggressiveness; its absence may increase impulsivity and aggressive responses. Psychological Factors -Threats to areas such as values, beliefs, and moral code could also lead to anger -Children learn aggression by observing and imitating behaviors of others, especially if that behavior is rewarded. Thus children who watch television violence or experience violence in the home learn aggressive ways of resolving problems.

What important documentation is needed regarding abuse or suspected physical abuse?

Important elements of the documentation of findings from the initial assessment include: 1. Verbatim statements of who caused the injury and when it occurred 2. A body map to indicate the size, color, shape, areas, and types of injuries, with explanations 3. Physical evidence of sexual abuse, when possible

Guidelines for Use of Mechanical Restraints

Indications for Use • To protect the patient from self-harm • To prevent the patient from assaulting others Legal Requirements • Multidisciplinary involvement • Appropriate healthcare provider's signature according to state law • Patient advocate or relative notification • Seclusion/restraint discontinued as soon as possible Documentation • Patient's behavior leading to restraint/seclusion • Least-restrictive measures used before restraint • Interventions used and patient's response interventions • Plan of care for restraint/seclusion use implemented • Ongoing evaluations by nursing staff and appropriate healthcare providers Clinical Assessments • Patient's mental state at the time of restraint • Physical examination for medical problems possibly causing behavioral changes • Need for restraints Observation • Staff in constant attendance • Complete written record every 15 minutes • Monitor vital signs • Assess range of movement • Observe blood flow in hands/feet • Observe that restraint is not rubbing • Provide for nutrition, hydration, and elimination Release Procedure • Patient must be able to follow instructions and stay in control • Termination of restraints • Debrief with patient Restraint Tips • Physical holding of a patient against will is a restraint • Four side rails up is a restraint except in seizure precautions • Keeping a patient in his or her room by physical intervention is seclusion • Tucking sheets in so tightly patient cannot move is a restraint • Orders for seclusion/restraint cannot be prn ("as needed")

•What information should not be obtained during Indira's initial medical exam?

It is appropriate to obtain all of the following at this point, with one exception: •Information from the patient—except asking what she might have done to provoke sexual assault. This is never an appropriate question and has been referred to as victim shaming. It is a major reason sexual assaults go underreported. •Documentation of biological and physical findings •Collection of evidence •Follow-up as needed to document additional evidence

Psychological Effects of Sexual Assault

Long-term effects of sexual assault-depression, suicide, anxiety, and fear. Other consequences of this horrific offense include difficulties with daily functioning, low self-esteem, sexual dysfunction, and somatic (physical) complaints. Victims of incest may experience a negative self-image, depression, eating disorders, personality disorders, self-destructive behavior, and substance misuse. A history of sexual abuse in psychiatric patients is associated with a characteristic pattern of symptoms that may include depression, anxiety disorders, chemical dependency, suicide attempts, self-mutilation, compulsive sexual behavior, and psychosis-like symptoms.

There are three basic types of neglect Describe: } Physical? } Educational? } Emotional?

PHYSICAL } Failure to provide adequate food, clothing, or hygiene. } Reckless disregard for the child's safety, such as inattention to hazards in the home, drunk driving with kids in the car, leaving a baby unattended. } Refusal to provide or delay in providing necessary health care for the child. } Abandoning children without providing for their care or expelling children from the home without arranging for their care EDUCATIONAL } Failure to enroll a child in school } Permitting or causing a child to miss too many days of school } Refusal to follow up on obtaining services for a child's special educational needs EMOTIONAL } Inadequate nurturing or affection } Exposure of the child to spousal abuse } Permitting a child to drink alcohol or use recreational drugs } Failure to intervene when the child demonstrates antisocial behavior } Refusal of or delay in providing necessary psychological care

Define: Seclusion and Restraint What guidelines and protocols, and legalities need to be implemented if a patient were to be in restraint?

Seclusion •Involuntary confinement alone in a room that the patient is physically prevented from leaving Restraints •Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement __________________________________________________________________________ --Once in restraint, a patient must be directly observed and formally assessed at frequent regular intervals for the level of awareness, level of activity, safety within the restraints, hydration, toileting needs, nutrition, and comfort --Use only to protect client or others from harm --Legal requirements - Team involvement - Less restrictive measures attempted and failed --Assess - Client's mental state/status - Risks to clients - Need for restraint - Least restrictive methods --Highly regulated requirements, Debriefing, and teamwork/safety guidelines: -The team should be organized before approaching the patient so that there is a clear leader and each team member knows his or her individual responsibility -The team leader communicates with the patient in a calm steady voice indicating decisiveness, consistency, and control.

Defining Characteristics of Rape-Trauma Syndrome

Shame Guilt Helplessness Powerlessness Dependence Low self-esteem Depression Mood swings Aggression Anger Agitation Revenge Substance abuse Suicide attempts Anxiety Fear Disturbed sleep Nightmares Sexual dysfunction Muscle tension Hyperalertness Dissociation Disorganization Shock Confusion Phobias Paranoia

Remembering Adam's situation, you decide you want to help prevent child abuse in the community and plan to hold classes for new parents. What are some topics that should be covered?

Specific topics should include: 1. Reducing stress 2. Reducing the influence of risk factors 3. Increasing social support 4. Increasing coping skills 5. Increasing self-esteem 6. Connecting parents to appropriate resources in the community that can meet their needs also is important.

Cycle of Violence (3 stages)

Tension-building stage -Begins with minor incidents such as pushing, shoving, and verbal abuse. -Victim often ignores or accepts the behavior due to fear of escalation -Abusers then rationalize that their behavior is acceptable -The abuser may try to reduce the tension with the use of alcohol or drugs, and the victim may try to reduce the tension by minimizing the importance of the incidents Acute battering stage -Occurs when the tension peaks -Triggered by an external event or by the abuser's emotional state -The victim may actually provoke the incident to remove the tension and fear and to move on to the honeymoon phase. Honeymoon stage -After the abuse occurs, the abuser and victim enter a period of calm -The abuser usually demonstrates kindness and loving behaviors. -The abuser, at least initially, feels remorseful and apologetic and may bring presents, make promises, and tell the victim how much she is loved and needed -The victim usually feels needed and loved and hopes for change -Legal proceedings or plans to leave initiated during the acute battering stage may be abandoned. Without intervention, the cycle will repeat itself. Over time, the periods of calmness and safety become briefer, and the periods of anger and fear are more intense. Each repeat of the pattern erodes the victim's self-esteem. The victim either believes the violence was deserved or accepts the blame for it. This can lead to feelings of depression, hopelessness, immobilization, and self-deprecation. without intervention, the cycle will repeat itself.

Sexual Assault Examination involves five steps:

The examination involves five steps: 1. Head-to-toe physical assessment, observing for signs of injury 2. Detailed genital examination, observing for signs of injury 3. Evidence collection and preservation 4. Documentation of physical findings (both written and photo documentation) 5. Treatment, discharge planning, and follow-up care

Shaken baby syndrome

The leading cause of death as a result of physical abuse usually occurs in children younger than 2 years old. Injuries are a result of the brain moving in the opposite direction as the baby's head. A baby who has been shaken may have respiratory problems, bulging fontanels, retinal hemorrhages, and central nervous system damage resulting in seizures, vomiting, and coma

Physical Trauma examination/process: ? (detailed)

The nurse will inspect and palpate for any signs of injury. --Recent injuries may not show visible bruising. Palpating the skin and finding tender spots can improve evidence collection and further documentation of an injured site. --Physical signs of injury post-sexual assault can include injuries to the face, head, neck, extremities, and anogenital areas. --Physical injuries should be carefully documented (i.e., size, color, description, and location of injury), both in narrative and pictorial form using preprinted body maps, hand-drawn copies, or photographs. --If an injury is present, ask the patient if she knows how that injury occurred. It is important to recognize that many reported cases of sexual assault have no physical signs of injury. The nurse will collect and preserve legal evidence --blood; hair samples; oral swabs; nail swabs or scrapings; and anal, genital, or penile swabs. --Facilities may have standardized sexual assault evidence collection kits that provide direction on how to collect and preserve evidence. This can be helpful to nurses and other clinicians who do not have specialized training in evidence collection and preservation. The nurse takes a gynecological history --Date of the last menstrual period and the likelihood of current pregnancy, and assesses for a history of sexually transmitted infections. --A detailed genital examination, with a speculum, is needed to observe for signs of injury for the female patient. If the patient has never undergone a genital examination, the steps of the examination will need to be explained. The nurse plays a crucial role in reducing revictimization -- Refers to the trauma of the examination itself because the patient may experience it as another violation of her body. --Recognizing this, the nurse can explain the examination procedure in a way that will be reassuring and supportive.

Sexual Assault Chap 29 Sexual Assault and Sexual Violence

Unwanted sexual advances and sexual harassment ◦Stranger rape ◦Marital rape ◦Date rape ◦Drug-facilitated sexual assault ◦Incest ◦Human sex trafficking ◦Female genital mutilation

Emotional abuse Provide examples of: }Verbal Abuse }Withholding Affection }Corruption }Extreme Punishment

V.A }Belittling or shaming the child: name-calling, making negative comparisons to others, telling the child he or she is "no good," "worthless," "a mistake." Habitual blaming: telling the child that everything is his or her fault. W.A} Ignoring or disregarding the child }Lack of affection and warmth: Failure to hug, praise, express love for the child Corruption} This involves causing a child to witness or participate in inappropriate behavior, such as criminal activities, drug or alcohol abuse, or acts of violence.

Evaluation- sexual assault ?

We consider sexual assault survivors to be in recovery if they are relatively free of any signs or symptoms of acute stress disorder and PTSD. Signs of recovery include the following: • Sleeping well with few instances of episodic nightmares or broken sleep • Eating as they did before the rape • Being calm and relaxed or only mildly suspicious, fearful, or restless • Getting support from family and friends • Generally positive self-regard about themselves • The absence or only mild instances of somatic reactions • Returning to pre-rape sexual functioning and interest In general, the closer the survivor's lifestyle is to the pattern that was present before the rape, the more complete the recovery has been

Specialized Sexual Assault Services

sexual assault nurse examiners (SANEs) ◦RNs with specialized training in caring for sexual assault patients ◦Demonstrated competency in conducting medical and legal evaluations ◦Ability to be an expert witness in court Sexual assault response team (SART) Members include nurses, physicians, attorneys, social service workers, advocates, mental health professionals, forensic laboratory personnel, and other collaborative agencies

Signs of Neglect

} Clothes that are dirty, ill-fitting, ragged, and/or not suitable for the weather } Unwashed appearance; offensive body odor } Indicators of hunger: asking for or stealing food, going through trash for food, eating too fast or too much when food is provided for a group } Apparent lack of supervision: wandering alone, home alone, left in a car } Colds, fevers, or rashes left untreated; infected cuts; chronic tiredness } In babies, failure to thrive; failure to relate to other people or to surroundings

Signs of Sexual Abuse

} Inappropriate interest in or knowledge of sexual acts One telling clue is when a child acts out sexual interactions in play, for example, with dolls } Seductive behavior Masturbation may be excessive in sexually abused children } Reluctance or refusal to undress in front of others } Extra aggression or, at the other end of the spectrum, extra compliance } Fear of a particular person or family member

Behavioral Indicators of child abuse Child behaviors you can see?

} Self-destructive } Withdrawn and/or aggressive - behavioral extremes } Arrives at school early or stays late as if afraid to be at home } Chronic runaway (adolescent) } Complains of soreness or moves uncomfortably } Wears clothing inappropriate to weather, to cover body