Violence Notes PDF

[Violence & Advocacy] - It is important to be aware of the potentially triggering nature of this topic. - Students are encouraged to leave the discussion if they feel uncomfortable. - Resources are provided for students who may need support during or after the discussion. - T...

[Violence & Advocacy] - It is important to be aware of the potentially triggering nature of this topic. - Students are encouraged to leave the discussion if they feel uncomfortable. - Resources are provided for students who may need support during or after the discussion. - The learning outcomes for this topic are to: - Examine common characteristics of victims and victimizers. - Describe physical and psychological effects of abuse and assaultive behaviors on victims. - Identify nursing diagnoses, goals of care, and interventions for victims and victimizers of abuse and assault. - Examine resources for victims of abuse and assault. - Evaluate the effectiveness of intervention strategies. - Explore nursing advocacy and ethical dilemmas related to violence and assault. **[What predisposing factors exposes an individual to turn towards aggression?]** **Modeling**: this is one of the strongest forms of learning: it refers to remodeling a behavior or response. So, if they see a parent that turns towards aggression, they are in turn are more likely to have that response in the same situation. **Operant Conditioning**: this is when a behavior has been reinforced. think temper tantrums: positive reinforcement is a response to a behavior that is pleasurable for an example: a child having a temper tantrum gets what they wanted whether it be candy, or a toy etc. The positive reinforcement of their behavior was the toy! This teaches them the correlation between throwing a tamper and getting what they want. **Negative Reinforcement:** does not reinforce a negative behavior it reinforces the behavior that removes the negative stimulus. EX: a person with PTSD that avoids a car after being in a car acidulent: getting in the car causes them discomfort and avoiding cars prevents that discomfort. Thus, the negative reinforcement comes when they avoid cars and do not have to deal with the discomfort. [Psychoanalytical theory]: this theory says that people are naturally aggressive and if their basic needs are not met, they can act out. [Neurobiological theory]: focuses on how the brain and chemicals in the body can lead to aggression. For example: issues in certain parts of the brain like the temporal lobe can cause people to have more emotional or aggressive reaction. Things like a an imbalance of neurotransmitters such as norepinephrine, dopamine or serotonin, or head injuries, seizure disorders, malnutrition, brain tumors or lesions and substance abuse can all mess with the brains ability to control aggression. [Social learning theory]: people can pick up violent learning behaviors from those around them. If someone is in a high-risk group, like a gang they're more likely to pick up violent behaviors. [Sociological theory]: explains that society and culture can make aggression seem more acceptable. For an example, men are less likely to report being abused because society might downplay violence against them and some families teach that violence is a normal way to communicate. [Psychosocial issues]: like being isolated with others, having negative relationship with family, acting on impulse, or dealing with unrealistic expectations and stress can also make someone more aggressive. SO AGRESSION AND VIOLENCE COME FROM A MIX OF BRAIN CHEMISTRY, LEARNED BEHAVIORS, SOCIETIAL INFLUENCES, AND PERSONAL CIRCUMSTANCES. Risk for violence: Age: 15% of death people aged 15-24 being due to homicide Culture: different cultures have varying view of how acceptable violence is Socioeconomic status: families living in poverty often experience more stress, which can lead to violence. This stress can be made worse by things like lack of supervision, living in dangers neighborhoods, or not having positive activities for children. For instances, research shows that boys under 13 who don't live with fathers are more at risk for violence and gang membership is often going to be linked to an absents father. Tragically 30% of women who are homicide victims are killed by their spouses, boyfriends, or former partners. Where someone lives matters as well: crime is more common in areas where families struggle financially, and more crowded places tend to see more violence. Schools also play a role: if a school doesn't enforce rules or if students are performing poorly peer pressure can lead to violence. Values and beliefs such as those tied to religion or culture normal can affect how people view violence, for an example men are less likely to report being abused by women which reflects those societal attitudes. Substance abuse is another factor, people who are under the influence may become easy targets or commit crimes to support their habits. & lastly, access to community services like youth programs or affordable houses and mental health services can either help reduce violence or if they're lacking contribute to it. **[ASSAULT]** Assault is defined as an intentional act by one person that creates an apprehension in another of an imminent harmful or offensive contract. Townsend defines assault as an act that results in a person's genuine fear and apprehension that he or she will be touched without consent -May be an act of violence by physical force and it excludes unintentional act of violence meaning if it occurs when someone is mentally unstable or someone that is just caught in the crossfire \- Aggravated assault is going to involve the use of a weapon whether it be a gun used to pistol whip someone, a bat, or a knife. -Extreme forms of assault result in homicide for example, a shooting or GSW, stabbing or knife wounds and the victim ends up succumbing to their injuries ect. Low self-esteem though they may mask this by appearing to be in control. Doubting their loyalty These individuals often have depression, suicidal thoughts, anxiety and nightmares Profiles of Victim: Many victims rationalize the abuse, believing that it is their fault for not meeting their partners needs or for causing their abuser's stress. They may fear leaving due to threats of harm including threats of homicide or not being allowed to take their children In most cases the male is the dormant partner, though this is not always true Victims often isolate themselves from friends of family, as they may feel that their abuser is suspicious of their relationships They may experience feelings of inadequacy and self-blame. Believing that they have failed as a spouse, parent, or home maker. Many victims modify their behavior in attempt to avoid provoking their partner. Trying to be the perfect wife or partner but no matter how hard they try the violence continues -- this leads to feelings of powerless or helplessness where they feel like nothing that they do can stop the abuse. Some victims end up turning to alcohol or drugs to numb the emotional and physical pain of their situation. Depression and suicidal thought are common as victims may see these as potential ways to escape the abuse. Victims often suffer from anxiety and nightmares, further highlighting the deep emotional impact of the violence they ensure. Profile of Abuser: Poor coping skills: manifest as behaviors as in kicking things, throwing things, yelling, turning blaming others for their own low self-worth Narcissist trails usually present as well, with their needs always taking priority IE: demand things like where is my dinner? Without any regard to their partners feelings or situation. In family semester Extremely jealous and possessive constantly Relationships inside this conditional love, Rigid [Cycle of violence] **Begins with the [TENSION - BUILDING] phase: which can last anywhere from weeks to months and sometimes even years!** Abuser: during this time the abuser becomes increasingly jealous and possessive, fearing rejection and that heir partner may leave. They are quick to anger but also quick to apologize -- Often turning to drugs or alcohol and minor battering might occur. Abusee: The victim in response becomes to this nurturing and compliant feeling as though they are walking on eggshells. They rationalize the abuser's behavior and take the blame for the abuse. They also tend to with withdrawal from others and sense the buildup towards more severe violence **Next is the [ACUTE BATTERING] phase: which can last up to 24 hours** During this phase the abuser justifying their behavior as teaching the person a lesson. They also will minimize the severity of the abuse or may claim to not remember it -- often blaming drugs or alcohol. The victim meanwhile may hide from the abuser and in cases of severe injury or fear of death, they may seek help. However, in many cases they attempt to hide the abuse from others. **Finally, there is the [HONEYMOON] phase** This is where the abuser begs for forgiveness and promises it will never happen again and believes that they can control this behavior. The victim however: sees this loving phase as a reason to stay often attempting to stop any legal proceeding and holding onto that hope that things will change. \*\*Physical signs of battered women\*\* - Injuries on the head, neck, & shoulders [which may result from actions like hair pulling or being grabbed around the neck.] These injuries can lead to complaints of **HEADACHES, OR NECK PAIN** and victims [may need to see a doctor or chiropractor for these issues!] - Black eyes are COMMON -- and often come with strange explanations like \*running into a doorknob even when the height or location of the injury doesn't match the story - Injuries during pregnancy - [Sprains, dislocations or broken bones: **OFTEN IN VARIOUS STAGES OF HEALING!** ] - Object patter left of body - Repeated ER/healthcare facility visits - **Traumatic Brain Injury (TBI): \*\* ACUTE & CUMULATIVE EFFECTS OF TRAUMA\*\* Screening for TBI and educating the client about the risk of repeated head trauma is critical in providing comprehensive care. The type of TBI that most often occurs in domestic violence victims is chronic traumatic brain encephalopathy from repeated head blows!** So, why do they stay? Retaliation: as many of them are threatened with death both for themselves and their children if they tried to leave. Losing custody of their children Financial and Physical dependence can also play a major role. Especially if this client has disabilities or have been kept from working for years that have kept them reliant on the abuser. Lack of support network Hopefulness Lack of attention to danger [THE HIGHEST RISK FOR A VICTIM IS WHEN THEY DECIDE TO LEAVE!] [THE DANGER ESCELATES SIGNIFICANTLY DURING THIS TIME!] ***[\~ nURSING iNTERVENTIONS \~]*** - SHORT term: includes assessing for immediate danger and ensuring the patient that they are not to blame. Address physical injuries, ensure privacy, allow verbalization of feelings - Explore need for home care services or alternate living arrangements to ensure the safety of the victim and any children. - If a nurse suspects a patient may be experiencing domestic violence, the detail of questioning will depend on *what indicators they have observed* - Nurses should first begin with broad questions such as: how are things at home? How are you and your partner relating? Is there anything else happening that may be affecting your health? - Then transition to more specific questions linked to clinical observation. These include: you seem very anxious, is everything alright at home? When I see injuries like this I wonder if someone could have hurt you? Is there anything else that we haven't talked about that might be contributing to this condition? - From there we can become more direct with our line of questioning: Are there ever times where you are frightened of your partner? Are you concerned about your safety? Does the way your partner treats you ever make you feel unhappy or depressed? I think that there may be a link between your illness and the way that your partner treats you, what do you think? - The domestic violence shelter and services can provide help with many different things for a victim of domestic violence. Characteristics of Child Abuse - **Physical:** non accidental injury like unexplained bruises, fear of the caregiver, or conflicting stories from the caregiver who may describe the child negatively. - **Emotional:** Belittling, ignoring or blaming the child. Often leading to extremes in behavior delayed development and a lack of attachment. - **Sexual:** Unusual interest or avoidance of all things of a sexual nature, sleep problems, nightmares, unusual sexual knowledge for age, say their bodies are dirty or damaged, fear of something being wrong with their genitals, aspects of molestation in drawings, games, or fantasies. - **Neglect:** Failure to provide physical or emotional needs with indicators like poor hygiene, frequent absences, stealing food, and inappropriate clothing. Its often linked to caregivers who seem indifferent, depressed, or involved in substance abuse. Profile of child abuser: Oftentimes the abuser has suffered abuse when a child. They expect their child to fulfil their emotional needs which makes them prone to depression. They often have frequent outburst of anger and rage and have a low frustration tolerance. It's very common for these individuals to abuse substances. They often have poor knowledge of child development and have very poor impulse control Physical Signs of Abuse **Behavioral & Psychological Characteristics Child:** Exhibit **[physical]**, **[emotional]**, & **[psychological]** signs -Fearful of caregiver or experience developmental delays **\***One common sign: [unusual reaction to pain:] when they may not cry or react when approached by an examiner, even during painful procedure **\*\***These children frequently struggle academically & they may act either overly mature -- or -- overly infantile for their age **\*\***Self harm, running away from home, and suicidal thoughts are also common indicators - Some children may turn to drugs or alcohol as a way to coupe and oftentimes have difficulty forming peer relationships -- - Sexual abuse: - Children may show unusual interest in or complete avoidance in unusual sexual topics - They may also suffer from sleep problems or nightmares - Possess sexual knowledge that is inappropriate for their age Adverse Childhood Experience Increase the risk for a wide range of behavior and psychological illnesses such as depression, eating disorder, anxiety, hypersexuality, suicidal ideations, borderline personality disorder, PTSD Physical Signs of Abuse & Neglect in the Elderly - Malnourishment - Dehydration - Fecal or urine smell on the person - Dirt, fleas or lice on the person - Pressure ulcers, sores, skin rashes - Bruises, abrasions, fractures, hematomas, or grip marks on arms - Multiple injuries in various stages of healing - May lack needed items: medications, glasses, hearing aids, etc. Behavioral & Psychological Characteristics in Elderly Victims - May have a physical or mental impairment. - May exhibit aggressive or very submissive behavior. - May fear reporting abuse - May be dependent on a caregiver. - May make excuses for the perpetrator. - May have low self-esteem - May experience hopelessness - May have financial issues. \>\>\>STRANGER RAPE PROFILE\ - [Controlled response] -- **VERY AMBIGIOUS**. The survivor might appear calm and collected but have a blunted affected. They can be confused and have difficulty make decisions and feel numb. After the first initial emotional response the individual can have a variety of reactions including embarrassment, fear, guilt, a desire for reverence, anger, anxiety and denial. - **Long-Term Reactions:** - **Compounded reaction:** additional symptoms emerge like depression, suicide, substance use disorders, psychotic behaviors or even suicidal ideations. - Silent Rape Reaction: [victim tells no one of the assault]: this could lead to abrupt changes in interpersonal relationships such as spouse or partner. They may start to have: NIGHTMARES, INCREASED ANXIETY DURING THE INITIAL INTERVIEW, THEY MAY HAVE MARKED CHANGED IN THEIR SEXUAL BEHAVIORS, AND A SUDDEN ONSET OF PHOBIAS OR NEW FEARS, AND THEY MAY HAVE NO VERBILIZATION THAT THE SEXUAL ASSAULT HAPPENED Rape Trauma Syndrome - Major Symptoms: - Re-experiencing the trauma where victims may have recurrent nightmares, flash backs or difficulties stopping memories related to the rape - Social withdrawal, often referred to as psychic numbing that involves a lack of response. - Avoidance of behaviors and actions actively trying to steer clear of thoughts or feelings that remind them of the assault. - Increased physiological arousal characteristics by heighted responses such as EXAGGERATED STARTLE REACTIONS, HYPERVILIGENCE, SLEEP DISTRUBANCES, AND TROUBLE CONCENTRATING - **Acute:** Initial response LAST BETWEEN DAYS AND WEEKS FOLLOWING THE INITIAL SHOCK. Marked by symptoms like heighted or diminished alertness dependent upon depending on the individual, numbness, disorganized thoughts, nausea and intense anxiety - **Outward Adjustment:** Can extend from months to years -- survivor appears normal on the outside while grappling with inner turmoil often using various coping mechanisms some healthy like therapy and others that are detrimental like some turning to substance abuse. - **Underground:** Survivors returns to their normal lives for years, suppressing but not fully processing the trauma. Seem to return to normal lives but unresolved issues may linger for years - **Reorganization:** Beginning to deal with the trauma which can be triggered by external events that bring back turmoil and unresolved feelings - this can lead to the underground phase if - **Renormalization:** Adjusting to life after trauma Nursing Diagnoses for Sexual Assault - **Victim/Surviror** - Powerlessness - Risk for delayed development - Rape-trauma syndrome - Ineffective coping - Interrupted family processes - Hopelessness - Risk for self abuse - Pain - Post-trauma response - Low self esteem - Impaired skin integrity - **Abuser** - Ineffective individual coping - Knowledge deficit - Noncompliance - Altered role performance - Self-esteem disturbance - Impaired social interaction - Risk for violence - Spiritual distress - Risk for trauma Nursing Care for Sexual Assault - Provide privacy -- CLOSED CURTAIN ROOM - Create a non-judgmental relationship -- USE NO EMOTION, ASK ANOTHER RN, ITS ABOUT THAT PATIENT AT THAT MOMENT. Not the nurses previous experience! - Allow the patient to have a sense of control: For example, they may only want a female nurse. NURSING PROCESS\ \ Avoid judgment, do not ask why questions Focus on abusers' behavior! Empower the client, but do not make decisions for them; provide them resources and allow them to make their own decisions NO WEAPONS -- ENSURE THAT THE CLIENT NOR THEIR PARTNER HAS A WEAPON. - The foundation to all treatment modalities for survivors of abuse or neglect - Requires [universal screening because anyone can be a victim]. - Trauma recovery is an essential aspect of overall care. - Ignoring or minimizing trauma can lead to revictimization and traumatization. Interviewing the Sexual Assault Patient - The interview should direct care and guide evidence collection. - It should be completed at the beginning of the visit with law enforcement. - Patient comfort should be a priority. - The patient should be fully dressed if possible. - A support person should be at the bedside **[EVEN IF ITS PASTORIAL CARE]** - The interview should include: \*\*Barriers used: -[Emotional responses]: clients are going to be in shock, and they are going to be very emotional if they are having expressed reactions -[Medical history] (EX: ELDER WITH DEMENTIA OR DEVELOPMENTAL DELAY AND THEY ARE NOT ABLE TO COMMUNICATE EFFECTIVELY Nursing Process: Assessment - Assess physical, psychological, and behavioral characteristics. - Determine if there is evidence of conflict between the patient and significant others. - Interview in private. - Look for inconsistencies between injuries and explanation. - Note any proneness to injuries. - Note any delay in seeking treatment. - Assess history of abuse or substance abuse. - Assess for stress in the family unit. - Complete a cultural assessment. - The RN needs to be aware of non-verbal signs of tension escalation. Mandated Reporting - Nurses have a legal obligation to report their findings according to state laws. - Mandated reports: - Child Abuse and Neglect - Elder Abuse & Neglect - Abuse or Neglect of a dependent individual - Reporters are immune from civil or criminal repercussions when acting in good faith. Nursing Preservation of Evidence - The priority intervention is medical stabilization. - Crime-related evidence is essential and must be safeguarded in a manner consistent with the investigation. - Common types of evidence: - Clothing, bullets, gunshot powder on skin - Bloodstains - Hairs, fibers, grass - Other debris found on the individual: glass fragments, paint, wood. - Clothing removed from a victim should never be placed in plastic bags -- always in paper bags - Clothing should not be shaken. - Wounds must be examined. - Clothing must be checked for evidence. - [Each separate item of clothing should be carefully placed in a paper bag, sealed, dated, timed, and signed]. - When trauma is sexual assault, a SANE may be called to the ER. - Treatment and evaluation of STIs must be completed promptly as the victim has a 72-hour time from for treatment - Pregnancy risk evaluation and prevention information should be provided. - Crisis intervention and arrangements for follow-up counseling must be arranged. Types of Evidence - SANE - **Physical:** Evidence that plays a crucial roll in linking a suspect to a victim. It plays a key role in identifying an aslant or disproving an alibi and connecting both the victim and suspect to a crime. Key form of evidence includes clothing, physical injuries that serve as use of force and genital injuries in which could indicate recent sexual contact and force. Body fluids, fibers, blood stains, and foreign objects may be present. - **Transient:** Some evidence-like saliva is considered to be transient and disappears quickly -- often within 30 minutes which is why it can only be used in forensic kits that are tested within 5 days of the sexual assault - **Touchable:** Evidence that is seen or noticed easily: examples like clothing, jewelry, blood stains, things that are easily recognizable! - **Trace:** Evidence that is microscopic: hairs, fibers, paint chips, etc. This is often what forensic kits focus on to ensure a thorough investigation. Investigation of Wounds - When clients present in the ED with undiagnosed trauma, a clinical forensic nurse specialist should make a detailed documentation of injuries. Failure to do so could interfere with the administration of justice should legal implications later arise. [Nursing DX: ] [For victim:] anxiety, ineffective individual coping, ineffective denial, fear, hopelessness, pain, post trauma response, rape trauma response, low self esteem [For abuser: ] [**Planning**:] **When planning care for this patient, providing safety of the survivor and the children [MUST BE PRIORITY]**! You will need to help them device an escape plan and determine content that they need when leaving such as documents, account, clothing, ect. Nurses should respect the women's right and ability over her life choices. We should hold perpetrators responsible for the abuse and their responsible for it as well. **[Implementation]** First make sure that the patient is STABLE THEN COMES SAFETY - Safety must be provided by separating the victim from the perpetrator and ensure them that they are in a place that is safe. Make sure you put an alias on the patients report. Ask yourself if there is a possible suicide or homicide risk. - Assist the patient in developing an escape plan if needed. - Report to law enforcement as required, make sure you understand the laws in your state even if the victim does not want to press charges - **[Follow guidelines for collection and preservation of evidence: ALWAYS DOCTUMENT INFORMATION AS OBJECTIVE INFORMATION AS TO WHAT THEY ARE DOING SUCH AS PACING, MAKING FIST OR RAISING THEIR VOICE ARE ALL SIGNS OF ECULATION]** - Consult a SANE when appropriate or able - Ensure sensitive, compassionate care while also ensure privacy and maintain the patient's dignity. - Thorough documentation is crucial this is done by using direct quotes - Collaborate with the team for interagency referrals such as: LAW ENFORCEMENT, SOCIAL WORK, THE CAROCEL CENTER (HELPS SURVIORS) IN OUR LOCAL COUNTIES, job counseling, legal assisting, housing. - Court mandated treatments may be offered for the perpetrator. **[Evaluation]** - Safety maintained - Victim demonstrates self-empowerment and improved self-esteem - Utilizing community resources to improve coping - Abuser accepts responsibility for violent behavior