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ISLAMIC UNIVERSITY OF GAZA FACULTY OF NURSING MASTER OF COMMUNITY MENTAL HEALTH NURSING. CH 38. 5. CHAPTER . 38. Care of Survivors of abuse and Violence. Prepared by : Ibrahim H. H. Rabeea 120093471 Supervised by : Dr. Ashraf El-Jedi. 2009 - 2010. SPECIAL POPULATION.

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CH 38





Care of Survivors of

abuse and Violence

Prepared by :

Ibrahim H. H. Rabeea 120093471

Supervised by :

Dr.Ashraf El-Jedi

2009 - 2010

care of survivors ofabuse and violence



Definition of Sexual Assault

Child Abuse

Intimate Partner Violence

Marital Rape

Elder Abuse

Nursing care of the Sexual Assault Survivor

Nursing Assessment

Nursing Intervention



child abuse
Child Abuse

The earliest from of family violence recognized in the health professional literature was physical abuse of children.

The many forms of child abuse, include physical abuse, emotional abuse, sexual abuse, and neglect.

Most maltreated children have been exposed to multiple types of abuse (Teicher et al, 2006)

Children who witness family violence and abuse are themselves victimized. Although they are often overlooked , they can be affected in many ways as a result of this abuse (box 38-4)

sexual abuse of children and adolescents
Sexual Abuse of Children and Adolescents

Sexual abuse is involvement of children and adolescents in sexual activities they do not fully comprehend and to which they do not or cannot freely consent because of physical cognitive and psychological immaturity. When this occurs within families, the perpetrators is a relative or surrogate relative who exploits the child for the perpetrator's sexual gratification.

Sexual abuse within families violates children's trust in an adult who is supposed to love and protect them.

Observable signs of sexual abuse include sexual acting out, physical aggression, excessive masturbation, social withdrawal, expressions of low self-esteem, impaired school performance,

and disturbed sleep.

Children also may develop a variety of physical

problems related to sexual abuse, including sexually transmitted infections; bleeding, soreness, or itching in or around the genitalia, perineum, or rectal area; recurrent urinary tract infections; chronic pain syndromes; or unintended pregnancy.

abdudion of children
Abdudion of Children

The vast majority of cases of child abduction involve a family member, usually a parent, taking or keeping the child in violation of a custody order or other legitimate custodial right. Cases in which a child or adolescent is kidnapped

by a stranger or slight acquaintance remain relatively rare.

A survey of family abductions found that children under age 6 years were particularly vulnerable to abduction, and abduction was more

likely to occur in families in which the child did not live with both parents. The majority of children abducted by a family member were abducted by their biological father; 25% were abducted by

their biological mother (Finkelhor et ai, 2002).

nursing assessment
Nursing Assessment

Nursing assessment of actual or potential child abuse begins with a thorough history and physical examination. Gathering a history of child abuse can be a stressful experience for both the nurse and the family.

The setting for the interview must be quiet, private, and uninterrupted.

In general, the child and the adults should be separated for the initial interview. However, deciding whether to do this depends

on the child's age and other factors. The nurse should honestly state the purpose of the interview and the type of questions being asked and describe the subsequent physical examination

nursing interventions
Nursing Interventions

When child abuse is suspected, the nurse must report it to protective services.

Nurses who work with violent families need to know exactly how protective services in their community operate. Ongoing professional relationships with colleagues at the agency will enable the nurse to remain informed about policies and reporting protocols and ensure successful coordination and continuity.

In cases of separated or divorced parents, all staff members involved in the care of the child must be clear about custody and visitation arrangements

for that child and about any restrictions placed on one or both parents' access to their child.

intimate partner violence
Intimate Partner Violence

The term intimate partner violence refers to a pattern of assaultive and coercive behaviors, including physical, sexual, and psychological

abuse and violence, that adults or adolescents use against their intimate partners

Abuse of female partners is the most widespread form family violence (Box 38-5). One in three adult women expectancies at least one physical assault by a partner during adulthood.

Sexual abuse, or marital rape, is part of the violence against female partners in almost one half the cases.

. A woman is in most danger of homicide when she leaves her abusive partner or makes it clear to him that she is ending the relationship. Risk factors for this degree of danger include having a handgun in the house, a history of suicide threats or attempts in either

partner, battering during pregnancy, sexual abuse, substance abuse, and extreme jealousy and controlling behavior. A statement often made by potentially lethal abusers is, "If I can't have you, no one can."

nursing assessment18
Nursing Assessment

The most prevalent cause of trauma in women treated in emergency rooms is abuse by an intimate partner.

women who experience partner violence are at increased risk of not receiving mental health care (Lipsky and Caetano, 2007

For example, the nurse must carefully assess a woman's beliefs regarding the abuse and responsibility for the abuse. Because many abusive male partners find an excuse for the violence, the woman may be unnecessarily accepting the blame for the abuser's actions.

If the patient is an abuser, mental state is also important, and the potential for further violence must be assessed carefully.

The safety of the abuser's survivors is a concern, as is treatment for the abuser.

nursing interventions19
Nursing Interventions

Many communities have treatment programs for abusive men. They have been found to be most effective when the court has ordered treatment, with punishment for noncompliance. Severely abusive men seldom admit they have a problem and often need to be mandated to enter and remain in


. A combination of strategies may be needed to get the abuser into treatment if he is not involved with the court. The type of referral chosen is extremely important. Long-lasting change is more likely if the treatment combines behavioral therapy

centered on anger control with a program designed to change attitudes toward women. Traditional marriage therapy or couple counseling as the only treatment is potentially dangerous to the woman because of the unequal power in the relationship and the possibility of retaliatory violence. Several themes expressed by women who have been in abusive relationships with men have been identified (Hall, 2003; Smith, 2003). These themes, outlined in Box 38-6, can help the nurse in assessing and intervening with women who have been in abusive

relationships. Interventions for survivors of intimate partner violence are presented in Box 38-7.

To empower an abused woman, one must first make sure she has accurate information on which to base her difficult decisions

Effective interventions are those that reduce isolation, empower through accurate knowledge about abuse and about community resources, and attend to safety needs.

elder abuse
Elder Abuse

Estimates of the numbers of older people in the United States who are abused, neglected, or exploited vary widely because the problem is underreported.

The U.S. Senate Special Committee on Aging estimates that there may be as many as 5 million survivors each year. Older adults are primarily abused, neglected, or exploited by their caregivers, most of whom are spouses, adult children, or other family members.

Personal care attendants, paid or volunteer, in the home or in long-term care facilities, also are perpetrators of elder abuse, neglect, and exploitation.

Because much of the abuse is by spouses, spousal abuse and elder abuse are often overlapping categories.


Older persons who are socially isolated, cognitively impaired, or dependent on others for daily personal needs seem to be most vulnerable to abuse and neglect. Social isolation also puts an older person at risk for financial exploitation by a family member or by scams perpetrated by non-family members. Characteristics of the abuser, such as having mental and emotional problems including substance abuse, create a family situation at risk for elder abuse

nursing assessment26
Nursing Assessment

It is important to assess for elder abuse in families where an emotionally ill person is financially dependent on aging parents. Family interviews should not focus exclusively on the patient but should also assess the interactions among family members for indications of verbal and physical control and aggression

Signs of neglect are more common than those of physical abuse.

Neglect may be manifested by poor hygiene, breakdown of the skin, malnutrition, dehydration, or underdosing or overdosing of prescriptive medications.

Determining whether the neglect is intentional is the key to planning a nursing course of action .

nursing interventions27
Nursing Interventions

may include counseling, therapy for mental disorders, or substance abuse treatment.

The success of various interventions for elder abuse is not yet know because research into this issue is scant. However, it is clear that an interdisciplinary approach is needed to address the complex components of elder abuse, neglect, and exploitation. Nurses in long-term care facilities and home health agencies may need to coordinate the services of health care professionals, state agencies, and community programs in cases of elder abuse (Burgess et al, Muehlbauer and Crane, 2006).

rape and sexual assault

Rape and sexual assault are concerns for individuals, families, and the community. Sexual assaults against women and children (the most common survivors) result in physical trauma, psychic and spiritual disruptions, and deterioration of social relationships. In addition, fear of rape and sexual assault shapes women's daily conduct as they restrict their activities in attempts to ensure personal safety.

Survivors of sexual assaults include women and men of all ages, social classes, races, and occupations.

Sexual assault disrupts every aspect of the survivor's life, including social activities, interpersonal relationships, employment, and career.

definition of sexual assault
definition of Sexual Assault

sexual assault is the forced perpetration of an act of sexual contact with another person without consent. Lack of consent could be related to the survivor's cognitive or personality development or feeling of fear or coercion or to the offender's physical or verbal threats. Sexual assault is not a sexual act but is instead motivated by a desire to humiliate, defile, and dominate the survivor.

A sexual assault occurs once every 6.4 minutes in the United states.

One in every six women will be raped in her lifetime.

Although a woman is four times more likely to be assaulted by someone she knows than by someone she does not know, the majority of these crimes go unreported even though rape is a felony.

marital rape
Marital Rape

marital rape is legally recognized in most states and is often reported along with physical abuse. Many husbands of abused women believe it is their right to have sex whenever they want.

survivors of marital rape describe forced vaginal intercourse; anal intercourse; being hit, burned, or kicked during sex; having objects inserted into their vagina and anus and other degradations while being threatened with weapons or beaten if they refuse to take part in these activities.

Marital rape is especially devastating for the survivor who often must continue to interact with the rapist because of her dependence on him. In addition, many survivors do not seek health care or the support of family members or friends because of embarrassment or humiliation.


Nursing Care

of the Sexual Assault Survivor

nursing assessment34
Nursing Assessment

The initial assessment is an important phase of the treatment of rape and sexual assault survivors. Although most nurses would quickly recognize the woman brought to the emergency department by the police after an attack by a stranger, many survivors of sexual assault are not so easily identified (Esposito, 2006). Therefore all nursing assessments must include questions to determine current or past sexual abuse.

Because people have different definitions of rape, the assessment question must be broadly stated, such as "Has anyone ever forced you into sex that you did not wish to participate in?" This question may uncover other types of sexual trauma, such as incest, date rape, or childhood sexual abuse. If the answer is yes, it can be gently followed with broad questions, such as "Can you tell me more about it?" or "How often has it happened?

Often the response may be hesitation, questioning, or an embarrassed laugh. When this occurs, the nurse can increase the patient's comfort by explaining that the question is routine because sexual assault is common and that it affects health in many ways

nursing interventions35
Nursing Interventions

Disclosure of sexual abuse indicates trust in the nurse. Rather than immediately referring the patient

elsewhere, the nurse's initial response of nonjudgmental listening and psychological support is essential.

The organizations listed in Box 38-9 may be useful when helping survivors of abuse and violence organize their resources.

People respond to sexual assault differently depending on their past experiences, personal characteristics, and the amount and type of support received from significant others, health care providers and the criminal justice system. The acute stage, immediately after the attack, is characterized by extreme confusion, fear disorganization, and restlessness. Although many will be visibly upset, some survivors may mask these feelings and appear to be outwardly calm or subdued.

The second phase involves the long-term process of reorganization. It generally begins several weeks after the attack. This phase may include intrusive memories of the traumatic even during the day and while asleep; fears; or phobias, such as extreme

Fears of being alone, being in a crowd, or traveling survivors often have a sense of living in a dangerous, unpredictable world and may become preoccupied with feelings of victimization and vulnerability. They may encounter difficulties in sexual relationships or in their ability to relate comfortably to persons of the same gender as the perpetrator. Some survivors develop secondary phobic reactions to people, places, or situations that remind them of the attack.



Any Questions