I’m concerned that your injuries may have been caused by someone hurting you…..

1. More women are injured by domestic violence than the total number of injuries sustained by women from car accidents, muggings and rapes combined. Battering is the most common cause of traumatic injury and death for a woman in the United States today

2. I’m concerned that your injuriesmay have been caused by someone hurting you…..

5. I’m concerned that your injuriesmay have been caused by someone hurting you.. You do not deserve that.

7. There will undoubtedly be times and incidents where you will come into contact with the victims of physical abuse resulting from domestic violence……. AS FUTURE NURSES……

8. AS FUTURE NURSES…… AN AMBULANCE OR POLICE OFFICER WILL HAVE BROUGHT THEM INTO YOUR HEALTHCARE FACILITY. PERHAPS THEIR PARTNER HAS BROUGHT THEM. THEY WILL NEED ALL OF YOUR KNOWLEDGE, SKILL, AND COMPASSION TO DEAL WITH WHAT HAS HAPPENED TO THEM PHYSICALLY, EMOTIONALLY AND MENTALLY.

9. AS FUTURE NURSES…… YOU WILL BE READY AND WILLING TO PROVIDE THAT…. BUT ALSO IN YOUR NURSING CAREER YOU WILL MOST ASSUREDLY BE CONFRONTED BY ANOTHER TYPE OF VICTIM. THIS VICTIM WILL ARRIVE ALONE AND NOT SEEM TO BE IN EXTREME DISTRESS. THEY WILL OFFER AN EXPLANATION FOR THEIR INJURIES THAT MAY NOT FIT WITH WHAT YOU FIND ON EXAMINATION.

10. As Future Nurses…… THEY WILL ALSO NEED THE BEST OF YOUR SKILLS AND KNOWLEDGE. THEY MAY NEED AN EVEN BIGGER DOSE OF COMPASSION. IT HAS TAKEN A LOT OF COURAGE FOR THEM TO SHOW UP AT YOUR FACILITY. IT WILL REQUIRE COURAGE ON YOUR PART AS WELL, TO FULLFILL YOUR ROLE AS NURSE.

11. As Future Nurses…… WE WILL PRESENT SUCH A VICTIM. WE WILL DISCUSS THE PRESENTING ASPECTS OF THE PATIENT, THE ASSESSMENTS AND FINDINGS, AND FINALLY….. THE OBLIGATIONS OF THE HEALTHCARE PROVIDER WHO FINDS THEMSELVES WITH SUCH A PATIENT.

12. The Nursing Process in Cases of Suspected Abuse A Clinical Assessment of the Potentially Abused Client

13. Components of the Assessment Process • Client presentation and non verbal communication • Physical assessment and evaluation • Neurological assessment and evaluation • Screening interview and Verbal Responses

14. AssessmentIndicators in Cases of Suspected Abuse Common Abuse type Injuries • Multiple Injuries • Bruising on the chest, abdomen or genital area • Minor lacerations • Injuries during pregnancy • Ruptured eardrums • Patterns of repeated earlier injury • Delay in seeking medical attention

15. Assessment Indicators in Cases of Suspected Abuse Other indicators of Abuse Client appears ashamed or evasive Gives an unconvincing explanation of her injuries Has recently been separated or divorced Seems uncomfortable or anxious in the presence of her partner Is reluctant to follow your advice Presents with children though little is wrong with them Presents at a facility outside their home area

16. Initial Client Presentation • Client presented to the facility at 0915 complaining of injuries to her hands and knees • Physical Profile • 32 year old Caucasian female • Married with one child, age 5 • Home address approximately 25 miles from facility • Well dressed and well groomed • Good initial physical condition

17. Initial Client Presentation • Client reported falling off her bike while riding home from the library this am. • Client stated it was “her fault” and no vehicles or other persons were involved.

18. Physical Assessment and Evaluation Initial Client Evaluation • Bruising on Breast • Two bruises noted • Left 2.5 cm • Right 3.0 cm oblong • Both bruises found to have yellow and green margins • Palpation of Ribs and Soft tissue • No rib fractures noted • Extreme tenderness over and around bruised areas

19. Physical Assessment and Evaluation Initial Client Evaluation • Abdominal Bruising • Large 8 cm deep bruise in upper right quadrant • Upper thighs • Left thigh • 7 cm rectangular deep bruise • Right Thigh • 4 cm egg shape bruise with yellow and green coloration at margin

20. Physical Assessment and Evaluation Initial Client Evaluation • Bilateral hand and knee abrasions with kitty litter size gravel deeply embedded in wounds • Puncture wounds • Two 0.2 cm wounds about 0.3 cm deep located on left scapula • Each wound has streaks of blue ink radiating in a downward direction

21. Physical Assessment and Evaluation Initial Client Evaluation • Questions raised by physical assessment • Is there trauma to the liver? • Is there trauma to the Ribs or underlying structure? • Internal Bleeding? • Were the puncture wounds due to a pen being used as a weapon? • Is there Partner Violence occurring?

22. Neurological Assessment and Evaluation • Assessment of Neuromuscular involvement • Evaluation of cranial nerve functions • Assessment of Mental Processes and Emotional State • Evaluation of the appropriateness of client responses and orientation Provides Two main functions

23. Neurological Assessment and Evaluation • Focus of Assessment • Client claimed a fall from a bicycle • Potential for hidden head or spinal injury • Suspected Abuse • Potential for hidden deficits • Potential for hidden injuries of the scalp and neck

24. Verbal Assessment The Tie that Binds Connects all parts of the assessment process into a whole Clarifies, defines and guides the assessment process

25. Verbal Assessment Listening to what is NOT said Tone, pitch and volume of voice will give clues to Client’s internal feelings. Fear Anxiety Pain

26. Verbal Assessment Listening to what is NOT said • Pitch and volume • Another clue to internal feelings • Fear • Voice can be very quiet or very loud • Anxiety • Shaky, vocal quiver, stuttering, stammering or high pitch • Pain • Difficulty speaking, holding of breath or gasping talk

27. Verbal Assessment Presentation Phase Nurse reviews available data Seeks out and asks for advice from other healthcare team members Arranges privacy for client communication Orientation Phase Sets the tone for the relationship by adopting a warm, empathetic, caring manner Closely observes client during the interview Prioritize the client’s problems and goals

28. Verbal Assessment Working Phase Encourage client to express feelings about their health or situation Provide information needed to understand and change behaviors Identifies Diagnosis, interventions and goals Take action to meet the goals set with the client Remind client your time with them is almost up Evaluate goal achievement with client Achieve a smooth transition for the client to other healthcare team members Termination Phase

29. The Nursing Response Wound Care Priorities Client Education and Assistance Dealing with your OWN feelings Ethical and Legal Standards and Requirements

30. Wound Care Priorities Bruises on Abdomen, Thigh and Breasts Older pre-existing injuries Abrasions with contamination on hands and knees Puncture wounds on left scapula

31. Dealing with your OWN feelings Acknowledge and address your own feelings Seek out other healthcare professionals to speak to about your feelings Understand Cultural and Ethnic Differences and embrace them Keep a Professional Attitude, remember Empathy NOT Sympathy

32. Dealing with your OWN feelings Acknowledge and address your own feelings Shock and disbelief Anger “Why did this happen” Use your Peers and other assets to assist you in dealing with your feelings Peers Clergy Counselors

33. Understand Cultural and Ethnic Differences Differences between cultures Yours is NOT theirs Parental/Social Support systems Are NOT yours Your view of current society Is NOT theirs

34. ProfessionalAttitude “BE” NON-JUDGEMENTAL Use compassion and touch CARING about the WHOLE person They are NOT a collection of symptoms or problems ADVOCATE BE a solution for the client

35. Client Education and Assistance I’m concerned that your injuries may have been caused by someone hurting you.. You do not deserve that.

36. Client Education and Assistance Approaching the Suspected Abuse Victim • Using a Framing Question • Over the past several years, domestic violence has become more of a health issue than ever before. Because of this I have started asking all my clients about it. • I’m concerned that your symptoms may have been caused by someone hurting you.. You do not deserve that. • I don’t know if this is a problem for you, but many of the women I see as patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I have started asking about it routinely.

37. Client Education and Assistance Acknowledge Abuse does not go away “You may not be ready to leave him yet” Advocate for Client safety Clients right to make their own decisions Validate the client Concern for the CLIENT “You did nothing to deserve this” Clarify “What he does to you is wrong” “You are not at fault”

38. Client Education and Assistance Use all phases of the Nursing Relationship NOW is your time to make a difference in the clients life Be non-judgmental The focus is wholly on the client and HER decisions Be Supportive Offer options and alternatives Use the Termination Phase to transition client to specialized team members

39. Client Education and Assistance Abuse is an interdisciplinary healthcare issue Immediately assess the safety risk to the client. Support the client in her decision REGARDLESS of what it is. Immediately involve the Partner Violence Liaison Ease client’s transition from your care to the Liaisons care. If none is available.. Offer to call a Domestic Violence Counselor Assist client in placing the call Stay with the client until the counselor arrives, transportation has been arranged, or the client has chosen to leave.

40. Client Education and Assistance Know who to call Keep current on your facilities requirements Become educated as a healthcare provider on the treatment and interventions for the victim of Domestic Violence Most of all… Care……..

41. It shall be the duty of every licensee who attends or treats a bullet wound………. or any other injury that the licensee has reason to believe involves a criminal act, including injuries resulting from domestic violence, to report such injury at once to the police of the city, town, or city and county or the sheriff of the county in which the licensee is located. Any licensee who fails to make a report as required by this section commits a class 2 petty offense…… Colorado State Statute 12-36-135

42. Legal and EthicalRequirements Governing Bodies Scope of Practice Facility regulations JCAHO American Medical Association State Law

43. Legal and EthicalRequirements Information for local assistance Make available hot line numbers to shelters and domestic abuse assistance programs. Caution The client to keep the phone number someplace safe and free from detection. Information for client education Offer the client web sites that give information concerning domestic abuse and agencies that can help. Caution the client to clear the history after using the computer so web sites visited are not obvious to another user. Offer written materials on breaking the circle of violence.

44. Legal and EthicalRequirements If you believe after examination and the client admits it to you, You must report it Your examination leads you to believe it is abuse BUT the client denies it… WHAT CAN YOU DO?

45. Legal and EthicalRequirements You MUST report it. You MUST document that you reported it and to whom you reported. You MUST document in exquisite detail your examination findings.

46. Legal and EthicalRequirements R. A. D. A. R. R ….REMEMBER to routinely ask questions about partner violence A ….ASK directly with specific Questions D ….DOCUMENT the injuries (including photographs if client allows it) A ….ASSESS the clients safety R ….REVEWING options with the client

47. Legal and EthicalRequirements What is legal is NOT always ethical KNOW your reporting will help the client Remember caring for an abused client is an interdisciplinary task and the decision most likely will not be yours alone to make

48. More women are injured by domestic violence than the total number of injuries sustained by women from car accidents, muggings and rapes combined. Battering is the most common cause of traumatic injury leading to death for a woman in the United States today