17. Special needs of the abused person

Physical abuse, sexual abuse, or neglect of a child or an adult are major health concerns that require the attention of health care professionals. The DSM-IV includes a section on Problems Related to Abuse or Neglect throughout the life cycle.

Child Abuse

DSM-IV CATEGORIES

Physical abuse of child (code 995.5 if focus of attention is on victim)

V61.21 Sexual abuse of child (code 995.5 if focus of attention is on victim)

V61.21 Neglect of child (code 995,5 if focus of attention is on victim)

The Federal Child Abuse Prevention and Treatment Act defines child abuse and neglect as physical or mental injury, sexual abuse negligent treatment, or maltreatment of a child under age 18 by a person responsible for the child's welfare. This law mandates that health care professionals report suspected abuse of any child to the appropriate state or county child protective service agency. Each state has its own guidelines for reporting abuse and determining whether abuse has occurred. (For further information, see Types of Child Abuse, page 316, and Characteristics of Abused Children, page 317.)

TYPES OF CHILD ABUSE

PHYSICAL ABUSE — nonaccldental Injury due to acts or omissions on the part of parents or guardians NEGLECT — failure to provide for the physical, emotional, medical, or educational needs of the child SEXUAL ABUSE — involvement of children In Intimate sexual activities, such as fondling, masturbation, and oral or genital contact EMOTIONAL ABUSE — verbal or nonverbal attacks on the competency of the child, resulting in a damaged sense of self, psychosocial impairment, and a distorted view of reality EXPLOITATION — use of the child for personal or financial gain, such as with inappropriate child labor or by involving the child in prostitution or pornography.

COMMUNICATION STRATEGIES

• Interact with the child at eye level. For toddlers and young children, squat down to the child's height. For older children, use juvenile-sized furnishings for conducting interactions.
• Stimulate discussion by making a feeling statement such as "My feelings get hurt when someone talks mean to me.”
• Use alternative methods, such as dolls, puppets, and drawings. to facilitate communication with the child only if the nurse has appropriate training and experience.
• Accept initial silence from the child, and communicate nonverbally. Be judicious about the use of touch because the child may have exposure only to "bad" touch and may not know the difference between good and bad touch.
• Involve the child in making simple choices or decisions.
• Talk about the child's strengths and other positive aspects.
• Encourage the child to act on his own behalf when in the company of other people.
• Encourage the child to question situations that are unfamiliar or uncomfortable by role-playing with the nurse ways to seek safety or find a trusted adult to help when put in uncomfortable or fearful situations.

NURSING DIAGNOSIS: FEAR

Probable Causes	Defining Characteristics
Dysfunctional family Unrealistic parental expectations Exposure to violence as a way to handle conflict Developmental disabilities	Anxious or apprehensive manner Aggressive behaviors Fight-or-flight response of he autonomic nervous system, such as palpitations, sweating, and pallor Silence in response to questions, with caregiver providing answers for the child

CHARACTERISTICS OF ABUSED CHILDREN

Recurrent individual injuries Multiple injuries or fractures in various stages of healing Involvement in numerous "accidents" Unexplained or suspicious bruises, abrasions, burns, damaged or missing teeth, strap or rope marks Head injuries or bald spots from pulling hair out Bleeding from body orifices Genital trauma Sexually transmitted diseases Verbalized accounts of being beaten, slapped, kicked, or involved in sexual activities Unexplained loss of weight or symptoms of malnutrition or dehydration Failure to thrive in infants Hygiene problems Inadequate clothing Abandonment by caregivers for significant periods Exposure to inappropriately harsh discipline Exposure to verbal abuse and belittlement Mistrust of others Extreme fear or anxiety Blunted or flat affect Depression or mood changes Social withdrawal Lack of appropriate peer relationships Sudden school difficulties, such as poor grades, truancy, and fighting with peers Nonspecific complaints of headaches, stomachaches, and eating or sleeping problems Clinging behavior directed toward health care providers Aggressive speech or behavior toward adults and abusive behavior toward younger children and pets Use of drugs or alcohol Runaway behavior Precocious display of sexual behaviors that would only be normal for an adult

Long-Term Goal The child will learn to verbalize feelings aroused by fear-provoking situations and develop a plan to seek help if abuse seems imminent.

Short-Term Goal #1: The child will express feelings related to fearful situations.

Interventions and Rationales

• Establish a warm, comfortable, trust relationship with the child. Much patience is required to develop a relationship with a child who's been abused. The child has a difficult time trusting because the people who should take care of the child have been abusive.
• Work with the child to identify and communicate feelings. Identifying feelings helps the child to acknowledge the traumatic situation.
• Encourage the child to express himself through talking or playing with dolls, figures, puppets, clay, or artwork. This type of play gives the child a new sense of control over difficult emotions.
• Let the child know that expression of negative feelings is acceptable. The child needs to know that its acceptable to express negative feelings.
• Teach the child how to express anger and hostile feelings in a safe manner, such as kicking a soccer ball and drawing a picture of current feelings. The child may have been exposed to only destructive ways of handling negative feelings; the child must learn how to express negative feelings in an acceptable manner.

Short-Term Goal #2: The child will identify ways to obtain help when feeling fearful or if abuse is imminent.

Interventions and Rationales

• Help the child identify the basic elements of personal safety, such as freedom from verbal abuse, freedom from threat of physical harm, having adequate adult supervision, and having basic physical needs met. This information can help the child identify the antecedents or beginning signs of violence or serious neglect.
• If age-appropriate, teach the child how to contact a helpful person and go to a safe location if abuse occurs. This knowledge gives the child the sense that management of the situation is possible.

NURSING DIAGNOSIS: SELF-ESTEEM DISTURBANCE

Probable Causes	Defining Characteristics
History of being abused History of basic needs being unmet Exposure to caregivers' verbal abuse of shaming and blaming by being told that the child deserves the abuse for being "bad"	Regressive behaviors Verbalization of expressions of fear, sadness, doubts about self Anger in response to small irritations

Long-Term Goal The child will demonstrate the ability to engage in age-appropriate self-care activities and appropriate peer relationships.

Short-Term Goal #1: The child will discuss psychosocial needs and begin to demonstrate self-care abilities.

Interventions and Rationales

• Help the child identify personal strengths. Identification of strengths reinforces self-esteem.
• Talk about what the child needs to do to feel safe and competent. This action not only conveys that the child is capable and competent as a person but also empowers the child to participate in self-care.
• Encourage the child's input to the plan of care and treatment by allowing the child to make choices and verbalize needs. Self-esteem can be developed by recognizing the child's viewpoint and encouraging participation and decision making in treatment where appropriate.
• Have the child initiate new self-care activities that can be successfully completed. Initial success enhances the child's self-confidence and may motivate the child to continue to participate in self-care activities.

Short-Term Goal #2: The child will begin developing appropriate peer relationships.

Interventions and Rationales

• Talk to the child about the value of interacting with peers, such as sharing ideas for play, sharing toys, playing games together and having a special friend with whom to converse. The chads interest in peer relationships may be aroused by imaginative discussion of the benefits of having friends.
• Discuss how people form relationships and make friends. The child may have little experience with having friends and therefore needs to be taught how to make friends.
• Identify the child's fears about having friends. Battered childrer. are often isolated from others and are fearful about being with a peer.
• Talk about the child's interests and what things would be enjoyable to do with others. The child needs to be permitted to be a child and to participate in age-appropriate activities.
• Encourage the child to spend some time with a peer or attend a group activity. Many of these children lack simple social skills; they require assistance taking the first step to interact with peers.

THERAPIES

The first aspect of care for abused children is to provide a safe environment and to intervene to treat their physiologic problems. Sometimes it's necessary to hospitalize or remove the child from the home situation if it seems likely that the child will be exposed to additional trauma. One-to-one work with the child begins the process of establishing trust, a prerequisite to a therapeutic relationship.

Individual Therapy

• Plan care that is sensitive to the child's abuse history. Avoid therapy rules or physical situations that may cause the child to experience the panic or trauma associated with the initial abuse experience. For example, being locked in a room or being asked to remain seated on a couch may cause the child to relive the abuse.
• Tell the child that the therapy session is a safe place, where feelings can be expressed.
• Encourage the child to talk about the abusive situation.
• Teach the child how to telephone child protective services, a health care provider, or police, and have the child practice what to say to obtain help.
• Teach the child basic survival skills, such as leaving the room or house when family righting occurs. Teach the child how to safely respond to sibling abuse.
• Tell all battered children that the abuse isn't their fault and that they aren't responsible for the behavior of their parents or other people.
• Help children deal with loss and help them realize that they aren't at fault for any changes, such as a separation from the offending person, loss of friends, and moving to a new location.
• Teach children about good and bad touch, that their bodies are private, and that they can say no to others who want to have sexual contact.
• Teach children that there are people whom they can trust and depend on. Help the children learn who these people are.
• Work with the child to develop a more positive sense of self
• If the child is manifesting abuse experiences by hurting others, work with the child to set limits and develop awareness of inappropriate expressions of anger.
• Help the child develop healthy peer relationships and participate in group activities.
• Refer to a support group when appropriate.

MEDICATIONS

Psychotropic medications aren't ordinarily used for children who have suffered from abuse, although a child may be prescribed a drug for short-term management of a particular symptom. For example, a child experiencing severe anxiety may be given an an-tianxiety drug, such as diazepam (Valium), chlordiazepoxide (Librium), or alprazolam (Xanax), along with individual psychotherapy. (See Appendix D for medication information.)

FAMILY CARE

• Work to decrease defenses and denial of the abuse while establishing a relationship with the parents. Rapport is established by helping the parents talk about struggles, crises, and other problematic situations. Encourage identification of feelings, and encourage the parents to see how poor impulse control and lack of coping skills lead to abusive behavior.
• Inform the families about the law and the need to report child abuse as well as the procedure for, purpose of and time required for the investigation.
• Help the parents identify their personal needs, and explore ways for them to meet these needs in a healthy manner.
• Teach the family to develop healthy coping skills for dealing with hostility and frustration, such as using time-outs, talking about negative feelings, seeking crisis assistance from helping professionals, and attending support groups.
• When appropriate, discuss specific issues such as shaken baby syndrome (violent shaking of a child when held by the shoulders or extremities, causing whiplash-induced intracranial and intraocular bleeding), sibling abuse, and Munchausen syndrome by proxy (a caretaker fabricates a story about illness in a child.
• Work on developing problem-solving skills, such as naming the problem and prioritizing tasks, and skills for performing activities of daily living, such as planning meals and scheduling a routine for getting tasks accomplished.
• Teach parents the developmental stages that their children with progress through, and help parents to have realistic expectations for each stage. Teach nonphysical disciplining strategies.
• Inform the parents about community education programs for parenting skills, such as Parent Effectiveness Training and Active Parenting.
• Refer families to agencies that can assist with handling problems related to food, housing, employment, and health care.
• Refer parents to drug and alcohol treatment facilities if substance abuse problems are identified.
• Give parents the child abuse hot line number they can call anytime assistance is needed.
• Encourage parents to attend local meetings of Parents Anonymous to establish a support system, identify personal unmet needs, and learn how to meet their own needs for self-esteem, love, and belonging.

Partner Abuse

DSM-IV CATEGORIES

V61.1 Sexual abuse of adult (code 995.81 if focus of attention is on victim)

Partner abuse occurs when a person over age 18 or an emancipated minor is subjected to an internal act of violence during an intimate, interpersonal relationship with another person. Conservative estimates indicate that, each year, 2 million to 4 million women in United States are abused by their male partners. The battered woman is usually afraid of the man's strength and combative ability and has no effevtive way of stopping him or defending herself. health care professionals aren't required to report partner abuse. The information given here focuses on the abuse of female partners because women are much more frequently abused by men than men are by women. Besides being the greatest cause of physical injury to women, battering poses great risks to unborn child. Many battered women are in danger of being killed when they take action to leave the abuser. (For further information, see Types of Partner Abuse)

COMMUNICATION STRATEGIES

• Encourage the client to talk about her situation.
• Use a straight forward approach. Ask direct questions such as "How were you hurt?" "Did your partner inflict these injuries?" "are you living with a persn who hurts you?"
• Identify the pattern of abuse, including degree of daner, severity, duration, type, and how it escalates.
• State that the client doesn't deserve to be abused, that it isn't her fault, and that battering is against the law.
• Acknowledge that the abuse is difficult for the client to discuss.
• Encourage the woman to explore all her feelings, including strongly negative ones, such as fear, anxiety, depression, anger, shame, and the desire for revenge.
• Acknowledge the client's feelings ofambivalence and lack of confidence in her ability to handle the situation.
• Ask the woman what she wants to do and how the nurse can be helpful to her.
• Avoid asking questions or making statements that blame the victim ("Why do you stay with him?" "You need to work on your self-esteem.").
• Suggest that the client put her energy into ensuring her personal safety and planning for her future rather than into trying to change the relationship.
• Establish a plan for safety, such as how to leave the scene and contact support personnel if abuse seems imminent.
• Talk about community resources, such as shelters and counseling services for abuse victims, and give the client the hot line abuse number. (For further information, see Sample Safety Plan and Teaching Topics for Partner Abuse, following page, and Clinical Indications of Partner Abuse)

TYPES Of PARTNER ABUSE

PHYSICAL ABUSE — any form of physical assault on the woman. Including slapping, punching, kicking, strangling, and striking with an object EMOTIONAL ABUSE — verbal and nonverbal statements that demean the woman and damage her self-esteem, causing her to feel less than a capable, competent person SEXUAL ABUSE — any attempts to force the woman to have sex against her will or to participate in sexual activities that she finds abhorrent ECONOMIC ABUSE — domination and control of the woman by making her dependent on the man for money and survival ABUSING MALE PRIVILEGE — treatment of the woman as an inferior person or a servant PSYCHOLOGICAL THREATS AND ABUSE — any threats or actions that the man makes to hurt the woman emotionally, such as humiliating or Mack-mailing her ANGER AND INTIMIDATION — use of aggressive expressions, actions, or verbalization to Intimidate the woman ISOLATION OR RESTRICTION OF FREEDOMS — use of coercion or threats to limit the woman's access to or communication with the outside world

SAMPLE SAFETY PLAN

Have the client memorize the hot line number or have it readily available. Have the client determine a safe place to go and plan how to get mare. If the client continues to live with her abusive partner, have her be prepared to leave quickly. Have the client know where medical care can be obtained if she is injured or experiences pain after being attacked. Encourage the client to develop a plan of action to notify police under certain dangerous circumstances. Instruct the client how to obtain-a restraining order or protection-from-abuse order, which she needs to carry with her always. Tell her to have extra copies available and to leave a copy with a friend. If the partner has been evicted from the house, have the client change existing locks, and have additional locks installed where security is needed.

TEACHING TOPICS FOR PARTNER ABUSE

Cycle of violence Safety issues Plan to leave abuser Manifestations of stress (anxiety, depression, posttraumatic stress disorder, dissociation) Therapy and support groups Use of psychotropic agents Health care for injuries and basic first aid Nutrition, sleep, and exercise information Care for children (secondary victims of partner abuse) Parenting skills and strategies Legal information, especially state and local laws Shelter information Social support

CLINICAL INDICATIONS OF PARTNER ABUSE
Agitation Severe anxiety Chronic depression Substance abuse Insomnia or nightmares Multiple, nonspecific somatic complaints Suspicious injuries
Common Injuries of battered women
Head injuries, such as concussions, bald patches, and retinal hemorrhage Neck injuries, especially strangulation marks Facial injuries, such as black eyes, missing teeth, and broken nose Unexplained soft-tissue injuries, human bites, or bums Unexplained fractures or dislocations, especially of the upper extremities Bruises or abdominal injuries in pregnant women History of spontaneous abortion Injuries to the genitalia

NURSING DIAGNOSIS: RISK FOR TRAUMA

Probable Causes	Defining Characteristics
History of conflict with partner Chronic lack of communication Chronic fatigue Persistent anxiety and depression	Previous exposure to physical, sexual, or emotional abuse with partner Acceptance of violence as a problem-solving measure Inability to make decisions Verbalization of feelings or being overwhelmed

Long-Term Goal The client will make contingency plans to assure her safety in the event of future assaults and will consider her legal options to end the abusive situation.

Short-Term Goal #1: The client will make decisions and plans that promote safety.

Interventions and Rationales

• Have the client discuss her situation and feelings about it. Battered women often blame themselves and feel powerless to change the abusive situation.
• Have the client identify cues to potential battering situations. It's helpful for the client to be able to identify antecedents to battering situations so that she can take measures to facilitate safety.
• Talk about ways to promote safety, and have the client develop a personal plan for safety. Having a plan for safety is protective and enables the client to have some control over the abusive situation and the consequences to herself and her children.
• Explain to the client that she can't change the batterer; she car. only change her responses to the batterer and the abusive situation. When the client relinquishes the unrealistic hope of controlling the abusing partner, she can focus her attention on the task ot helping herself.
• Assess the client for suicide risk and the potential for accidents Battered women may view suicide as a way out of an abusive situation. They are prone to accidents because of their high level of anxiety, which influences their ability to care for themselves and their children.

Short-Term Goal #2: The client will make a realistic assessment other situation and become familiar with her legal rights.

Interventions and Rationales

• Talk to the client about the prevalence of domestic violence. Telling the woman that violence in the home isn’t uncommon enables her to realize that her situation isn’t unique and that she isn r alone in her experience.
• Discuss the relative safety of remaining at home, and emphasize the need for a workable safety plan in response to the recurrence of abuse. Many women choose to remain with the abuser because of fear of failure, fear of physical harm or other retaliation, lack of resources, lack of self-esteem, and pressure from significant others. For some women, leaving is more dangerous than staying because many women are killed by their abusers after they have left the abusive situation.
• If the client has children, ask whether the children are also being abused. Action must be taken to report child abuse. Discussion about the effects of violence on children can mobilize the woman to do something about the situation.
• Discuss legal options such as a temporary restraining order (TRO) that can be used to protect the woman from the abuse. Women need to know that they can obtain a TRO for 7 to 10 days and then have a hearing for a permanent restraining order.
• Have the client obtain information about her rights, and make her aware of the local Legal Aid chapter. Have her contact the court that handles domestic relations for information about her right to file civil or criminal charges. Women need to know that it's a crime for a man to beat his partner. This information about a woman's rights is essential to have for possible future use because violent behavior tends to recur in relationships.

NURSING DIAGNOSIS: POWERLESSNESS

Probable Causes	Defining Characteristics
History of a dysfunctional family Extended period living in an abusive situation Depression Multiple persistent stressors	Manifestation of symptoms of anxiety Verbalization of having no control over the situation Great difficulty expressing feelings Fearful for safety of self and children

Long-Term Goal The client will gain an increase in control over her life by making positive statements about her abilities and by making decisions that promote safety.

Short-Term Goal #1: The client will discuss her situation and start to redefine herself as a person with strengths.

Interventions and Rationales

• Accept the client's statements about her pain and feelings of powerlessness. The client must feel free to vent feelings in order to establish a relationship with the nurse.
• Encourage the client to talk about situations in which feelings of powerlessness begin. This discussion can help the client develop awareness of cues that precipitate feelings of powerlessness.
• Encourage the client to recall how she has coped in the past with painful or problematic situations. This enables the client to acknowledge her past strengths and abilities to cope. identifying areas that she can control.
• Encourage the client to identify ways to satisfy her own personal needs and preferences in her situation. The effectiveness of interventions increases when the client is involved in making the change.
• Encourage the client to take personal credit for progress, such as expressing positive feelings (hope, purpose, or control) and making her own decisions. Acknowledging progress provides a positive sense of self and reinforces the clients dignity.

Short-Term Goal #2: The client will engage in problem-solving behaviors and use decision-making skills to change her situation.

Interventions and Rationales

• Discuss the importance of safety as the basis for all decisions. The client needs to recognize that all her actions must ensure the safety of her children and herself
• Teach and review problem-solving skills, such as ways to handle frustrations, or strategies to express anger safely and prevent the anger from being internalized. Teaching how to problem solve empowers the woman to better cope with her life stressors.
• Work with the client on the problems she identifies as a way to practice and reinforce newly learned decision-making skills. This exercise enables the client to implement safety and survival skills rather than remaining in the role of victim.
• Talk about available resources, such as counseling, women s groups, shelters, health care, and legal aid. Knowledge of available resources decreases the client's feelings of powerlessness.

STSESSORS THAT CONTRIBUTE TO PARTNER ABUSE

Unemployment Personal feelings or inadequacy Financial difficulties Spouse who's an underachlever Spouse with inadequate verbal skills Social Isolation or lack of social support Crises, such as occupational or other accidental injury, bankruptcy, and bereavement Pregnancy Chronic health problems or frequent illnesses Lack of a family religion or struggles about religion Partners having different values and lifestytes Unquestioned acceptance of mate dominance in the relationsip Substance abuse by one or both partners

THERAPIES

The treatment modalities recommended for abused women are individual, group, and family therapy. The priority of care in all interactions is the client's safety; therefore, a well-delineated plan needs to be in place. Usually, therapy is started after crisis intervention has occurred. The abusers must also participate in their own individual or group therapy because they need to work on their own personal issues and stressors. (For further information see Stressors that Contribute to Partner Abuse)These abusive people must develop ways to identify and appropriates handle their impulsive and explosive feelings as well as learn ho\\ to accept responsibility for changing their violent behavior.

Individual Therapy

• Discuss the woman's lifestyle and situation.
• Explore the pattern of violence that's occurring.
• Talk about the client's history, including family of origin, and how she forms relationships with others.
• Assess the client's vulnerability, and help her recognize persona! patterns of establishing destructive or dysfunctional relationships.
• Work on changing unhealthy thought patterns and ideas related to low self-esteem. Encourage the client to stop viewing herself as inferior to her partner.
• Have the client work to regain a sense of control and assertive stance in order to develop her personal power.
• Explain that the client is capable of protecting and caring for herself and her children.
• Teach the client about the cycle of violence: the tension-building stage, the acute battering phase, and the honeymoon stage. This information will give her insight into the dynamics of partner abuse.
• When appropriate, help the client process the abuse experience. Focus on how the experience affected the woman.
• Discuss and contribute to the client's plan for change.
• Continue to have the client evaluate and revise the plan for change to meet her and her children's needs.
• Encourage the client to seek information about public assistance, employment, health, advocacy, and legal recourse as her needs arise.

Group Therapy

• Encourage the client to interact with group members, sharing her situation, fears, and concerns.
• Reinforce the client's humanness and the fact that she isn't alone in her struggle with an abusive partner.
• Have the client identify what she needs from the group.
• Explore how change is possible for group members.
• Promote the client's contribution to other group members.
• Have the client use the support and feedback of group members as a way to learn and initiate change.
• Help the client become empowered and gradually begin to take control other life.
• Use the group to decrease the client's feelings of social isolation.
• Encourage group members to practice and strengthen their problem-solving and decision-making skills.

Family Therapy

• Focus on the needs and pain of each family member.
• Encourage each member to communicate, listen, support, and try to understand one another's perspective on the family situation.
• Identify the patterns of abuse or violent behavior in the family. Often, the pattern of abuse can be traced back through the generations.
• Discuss how the use of violence is a learned behavior that s passed through the generations as a method of solving problems.
• Focus on how to disrupt or break the pattern of abuse.
• Have the client, her children, and other appropriate extended family members discuss how the abuse has affected their lives.
• Encourage expression of feelings.
• Explain that the family can't change the abuser: rather, that person needs to take responsibility for his own behavior.
• Have family members work to identify and maintain their o\\-personal space and boundaries, including respect and privacy for others and ownership of thoughts, feelings, and behaviors.
• Work with family members to develop guidelines or rules to provide structure, and help them organize effective use of their strengths.
• Work to empower the client to stay in an adult role and to maintain the boundaries between the generations. Adults must act as adults, and children must act as children.
• Work to prevent involvement of family members with drugs or alcohol as a coping mechanism.

MEDICATIONS

• Psychotropic medications aren't ordinarily used for clients who have suffered from abuse.
• In some instances, a drug may be prescribed for short-term management of a particular symptom. For instance, a client who's experiencing severe anxiety may be given an antianxietv drug, or a client with severe depression may be prescribed an antidepressant drug to augment individual or group psychotherapy.
• In the past, many abused clients were prescribed antianxietv drugs and pain medications. Clients medicated with these drugs are less likely to appreciate their options and make decisions to help themselves and their children. Depressed clients who are medicated with appropriate antidepressants, however, are more likely to be able to make decisions and discover options.
• The unnecessary use of medications can be hazardous to an abused client and should be discouraged because of the increased likelihood of sedation, which can cause poor judgement or accidents from the central nervous system depressant effects. (See Appendix D for medication information.)

FAMILY CARE

Care for the entire family is appropriate when the family has identified abuse as a central problem and is working toward preventing abusive behavior from escalating. Such families may be feeling chaotic due to multiple stressors, or they may present themselves with the complaint that they don't get along. Tvpically, family members readily identify and discuss examples of verbal and emotional abuse: however, family members may be reluctant to acknowledge episodes of physical abuse.

• Work to identify social and situational stressors that impact negatively on the interpersonal relationships.
• Assess the possible effect of substance abuse on family dysfunction.
• Evaluate whether violence is a behavior used to deal with problematic situations.
• Teach and have the couple practice conflict resolution skills.
• Discuss the need to respect each person's personal boundaries right to privacy, safety needs, and right to personal space, along with acknowledging ownership of feelings and thoughts.
• Identify each partner's unmet individual needs as well as unmet shared needs; help partners devise plans to meet their own needs first. Partners who take responsibility for meeting their adult needs are better able to meet the needs of dependent children.
• Work with the couple to express their feelings and talk about negative or painful situations in non threatening ways.
• Have the couple work to change defensive coping styles and stop the use of projection, denial, displacement, and passive-aggressive behaviors.
• Encourage the couple to communicate their roles, needs, and expectations to each other in order to develop an understanding of these roles.

Rape

DSM-IV CATEGORIES

V61.1 Sexual abuse of adult (code 995.81 if focus of attention is on victim)

The National Institute of Mental Health defines rape as forced vaginal or anal intercourse, cunnilingus, fellatio, or intrusion of a body part or object manipulated by one person into the genital or anal opening of another person's body. The definition also includes the intentional touch of the victim's sexual parts accompanied by force or threats. Rape is an act of violence that occurs against the will and without the consent of the victim. The perpetrator uses threats, intimidation, or physical force to dominate the other person. During rape, the victim is reduced to the status of a mere object used to meet the rapist's need for power, control, and personal gratification. The rape victim displays symptoms of posttraumatic stress disorder and experiences a profound feeling of powerlessness, helplessness, and overwhelming threat to the sense of self. Many people who have been raped believe that they can no longer be responsible for ensuring their own safety needs. Victims of rape experience a disruption in the;' daily life activities during the initial crisis period and continue to have repercussions related to the trauma for years afterward.

PHASES OF THE RAPE-TRAUMA EXPERIENCE
Victims may display any number of these symptoms. The particular combination of symptoms that appear are unique to the victim and the circumstances.
Phase 1: Acute Phase
Physical injuries Tense, upset, angry, restless, or irritable behavior Frequent periods of crying Fearful behavior or manner Outward calm, emotional withdrawal, or self-control Flashbacks Numbness or flat affect Insomnia Inability to concentrate Preoccupation with feelings of personal responsibility for having been victimized and the asking of questions such as "What could I have done differently?" and "Was I responsible?"
Phase 2: Recovery Phase
Somatic symptoms — fatigue, headache, Gl or genitourinary disturbances, exacerbation of past physical problems, eating difficulties, musculoskeletal soreness Phobias or fear of traveling or being in a crowd Preoccupation with feelings of vulnerability Sexual difficulties Difficulty trusting and interacting socially with others, especially men

Although men can be rape victims, women are much more frequently raped in our society. Federal Bureau of Investigation crime statistics state that a woman is raped every 5 minutes in the United States. At current rates, one woman out of even,' four will be sexually assaulted during her lifetime. This section focuses on care of women because most rape victims are female. (For further information, see Phases of the Rape-Trauma Experience and Physical Care of the Client Who Has Been Raped.)

PHYSICAL CARE OF THE CLIENT WHO HAS BEEN RAPED

Obtain the client's consent for treatment, examination, photographs, and other procedures needed to collect legal evidence or effectively treat the client. Obtain and document a detailed health history, including a verbatim description of the rape. Provide assistance to the client as she undergoes a comprehensive physical examination. Be certain that the procedure is carefully explained and proceeds slowly. Stay with the client during the entire procedure. Collect the appropriate laboratory specimens and other potential evidence such as a blood sample for serologic treponemal antibody studies (syphilis); collection of semen, such as by hanging drop analysis; smears for the presence of sperm and their motility; presence of acid phosphatase in the vagina or rectum; cultures of the urethra, vagina, and anus for gonorrhea, chlamydia, and other bacterial infections; and analysis of foreign pubic hairs by the police laboratory. Be aware that correct collection and preservation of specimens of body fluids is essential because techniques such as DMA fingerprinting may be used to identify the offender. Explain pregnancy prevention, including the benefits and risks. Diethylstil-bestrol for postcoital contraception isn't routinely used but is available. For many women, pregnancy tests are obtained before initiating an intervention. Explain the necessity of obtaining follow-up care to check for sexually transmitted disease. Follow-up care is essential because sexually transmitted disease must be treated quickly and effectively. In some situations, prophylactic treatment with I.M. penicillin or oral ampicillin is given.

COMMUNICATION STRATEGIES

• Make supportive statements, such as "I'm so sorry this happened to you." "You're safe now." "I know you handled this situation right because you're alive."
• Help the client place the blame where it belongs, on the rapist rather than on herself
• If the client has difficulty recalling the event, considerate questions may be useful in helping her remember details needed for medical treatment.
• Let the client know that the nurse will remain with her during the examination, especially the gynecologic examination, and treatment.
• Discuss the follow-up for pregnancy and sexually transmitted diseases.
• Explain that there's no legal requirement for health care professionals to report a rape to the authorities. Encourage the victim to consider her legal option oppressing charges against the perpetrator. Give telephone numbers and names associated with local women's advocacy groups, victim assistance programs, domestic abuse and rape crises centers, and the sexual assault unit of the local police. After talking to the client, the nurse may be able to obtain consent to make a referral to a crisis intervention team or service.
• Identify and discuss the client's emotional response to the rape. It's common for women to feel humiliated, shamed, anxious, depressed, and unclean.
• Be sensitive to the client's need to make choices, and verbally support the decisions made.
• Explain the need for medical care, including testing for human immunodeficiency virus.
• Help the client make practical arrangements, such as not staving alone.
• Talk to the client about ways to cope when she is feeling overwhelmed and vulnerable.
• Discuss with the client how to tell family members or significant others about the rape.

NURSING DIAGNOSIS: RAPE-TRAUMA SYNDROME

Probable Causes	Defining Characteristics
Blaming by significant others Powerlessness Fears and anxiety about sexually transmitted diseases Preexisting health problems exacerbated by the assault New health problems caused by the assault	Anger Anxiety or depression Expressions of shame, embarrassment, self-blame, and humiliation Symptoms of posttraumatic stress disorder, including recurrent dreams of the rape, feelings of detachment and estrangement from others, inability to participate in a range of normal activities and hyper vigilance

Long-Term Goal The client will regain control over her own life by integrating the rape event and resuming an optimal level of functioning.

Short-Term Goal #1: The client will identify and develop the coping skills needed to reduce her level of anxiety and perceive the rape realistically.

Interventions and Rationales

• Discuss with the client the need to monitor and obtain care for physical injuries. The client must develop a plan to cope with physical health needs rather than ignore or deny them because unmet needs generate anxiety.
• Work with the client to identify situations that generate anxiety, such as going home alone after work or a social activity and plan strategies to avert these stressors. Anticipatory guidance can help the client plan ways to decrease stressful situations.
• Encourage the client to verbalize feelings of anger, guilt, fear, pain, and resentment. Talking about distressing feelings helps decrease their intensity.
• Talk to the client about displacing anger and other feelings onto herself or others. The client needs to direct anger and other hosti:e feelings about the rape to the perpetrator rather than attack herself or hurt or alienate supportive others.
• Assess the client for a tendency to resort to reckless or self-destructive activities for handling anxiety. Sometimes a client may resort to self-destructive behaviors as a result of negative feelings about herself after the rape.
• Help the client differentiate between poor judgment, such as walking alone, and blaming herself for the rape. The client may need to acknowledge that poor judgment placed her in unnecessary danger; however, the client needs a clear understanding that poor judgment on her part doesn't release the attacker from complete responsibility for the rape.
• Discuss with the client strategies for regaining control over her life situation. After a rape, the client struggles with redeveloping a sense of control over herself and her life situation.
• Work with the client to deal with nightmares or obsessive thoughts about the rape. The client needs to be reassured that the nightmares and intrusive thoughts are a normal response to stress that s been experienced and that they decrease with time.
• Talk to the client about the responses of shock, numbing, disbelief denial, and inability to trust that can occur after the trauma. The client needs to know that these feelings and responses to the rape are normal.

Short-Term Goal #2: The client will demonstrate the ability to make decisions about home, work, social, or school activities.

Interventions and Rationales

• Encourage the client to identify and pursue activities of the past that were helpful and pleasurable. The client may need assistance identifying and resuming usual activities, especially if a sense of fear is present.
• Discuss fears that impede the client's ability to make decisions about meeting daily needs. Many times the client procrastinates or withdraws from activities for fear of being unable to make a decision that feels comfortable.
• Encourage the client to talk about social, relationship, and sexual concerns. Discussion of the client's concerns can yield strategies for handling actual or potential problems with other people.
• Support the client's decisions, and don't impose persona] expectations or values on her. Its important to be sensitive to the client's needs, plans, and time line for making decisions: the nurse shouldn't try to influence them with a paternalistic approach.

THERAPIES

The basis for therapy with people who've been raped is to provide crisis intervention in order to help them regain their former level of functioning. The focus is on problem solving and decreasing the trauma the client is experiencing. Individual or group therapy is useful for the client after the initial crisis is over and the client is beginning to process the psychosocial impact.

Crisis Intervention

• Help clients express thoughts and emotions, regain some control over their lives, and decrease feelings of powerlessness.
• Explain that the rape wasn't the client's fault and that no one deserves to be raped.
• Explain that the decision to obtain health care is a positive way to handle the situation.
• Provide the client with support and written information to assist with coping at home.
• Have the client contact her family or a significant other, and work with the client to determine a place to go after leaving the health care agency.
• Provide the client with information about counseling services.
• Encourage the use of follow-up telephone counseling that's included in the treatment protocols for some emergency departments.
• Contact the client as part of the follow-up because the person in a crisis state may be unable to reach out to others for assistance.

Individual Therapy

• Have the client identify and discuss uncomfortable or intense emotions and adopt stress reduction strategies for handling these feelings, including engaging in vigorous exercise, creating a journal, art or music projects, relaxation techniques, and martial arts training.
• Help the client develop realistic expectations other recovery process.
• Explain that the client didn't cause the attack and that no one deserves to be raped.
• Work with the client to reassess her current view of human sexuality.
• Have the client talk about how the rape has influenced her level of functioning and behavior.
• Help the client formulate a plan to help her feel safe again, such. as changing locks, changing her work schedule, having another person to go places with, changing her telephone number, and going to self-defense classes.
• Work with the client to prevent secondary victimization or blaming the victim by refuting social myths about rape.
• Encourage the client to talk about her fears, feelings, and plans for the future.

Group Therapy

• Encourage clients to use the group as a place to obtain support, talk about feelings, and process the trauma.
• Have clients work on developing a positive sense of self.
• Have clients discuss, learn, and practice coping skills.
• Have group members work to promote each person's maximum level of functioning.
• Have clients participate in giving and obtaining feedback on coping behaviors.
• Encourage group members to connect with one another to decrease feelings of social isolation.
• Provide clients with psychoeducational and other health information.

MEDICATIONS

Clients who are victims of rape are usually not treated with medications. An antianxiety drug may be prescribed for severe anxiety or an antidepressant may be given for severe depression. (See Appendix D for medication information.)

FAMILY CARE

• Explain to the family about rape, including the process that the client will progress through and the typical emotional, cognitive, and behavioral responses.
• Educate the family about the facts and myths of rape.
• Talk to family members, and have them explore their feelings because they may also feel victimized.
• Encourage the involvement of necessary family members in assisting not only the client but also the significant other. This person may be overwhelmed by the trauma and unable to provide support for the victim.
• Talk to the significant other about the effects of becoming physically and emotionally distant from the client.
• Have family members explore their need to obtain counseling in the event they're overwhelmed by anger, shame, embarrassment, or humiliation.
• Explain to the family that the client doesn't have energy for making certain decisions, such as seeking health care, caring for herself or her children, and typical activities of daily living.
• Instruct family members not to impose their agenda on the client such as pressuring her to prosecute, notifying the police, and keeping the incident a secret.
• Make the family aware of the tendency for a rape victim to become socially isolated, and help the family develop a plan to prevent this from occurring.
• Caution the family about becoming overprotective because this may reinforce client fears and produce client dependency.
• Discourage the family and client from attempting to obtain revenge through violent acts directed at the rapist.
• Explore whether the spiritual beliefs of the client or family can provide a sense of comfort during this stressful period.

Elder Abuse

DSM-IV CATEGORIES

V61.1 Physical abuse of adult (code 995.81 if focus of attention is on victim)

Elder abuse is defined as any deliberate or negligent action that produces physical or emotional injury, malnutrition, or exploitation of a dependent elderly person. Often, the person is refused access to food, clothing, shelter, or health care. Most elderly victims don't seek assistance for their abusive situation because or fear of abandonment, institutionalization, or retaliation that's worse than the abuse they currently endure. Typically, abusers of the elderly are related to the victim and live in the same household or else they're the primary caregivers.

Unlike child abuse, elder abuse isn't addressed by federal laws. Forty-seven states have laws that require the reporting of elder abuse. The problem is that at the local level, there is often a lack of funds to support services and programs that protect these abused adults. (For further information, see Types of Elder Abuse, and Indicators of Abuse in the Elderly.)

COMMUNICATION STRATEGIES

• Be aware of nonverbal communication because elderly people may not be verbal because of chronic health problems, disorientation, the effects of aging, fear of retaliation, or embarrassment.
• Recognize that it takes time to establish a trusting relationship and for the elderly person to admit that abuse is present.
• Use nonverbal strategies to demonstrate caring, and facilitate the elderly person's physical and emotional comfort.
• Refrain from expressing judgment or disapproval and from making unspoken assumptions about the abusive situation.
• Through conversation and nonverbal communication, convey an interest in the client's personal needs, health, and well-being.
• Ask questions to assist the elderly person with discussing abusive or negligent situations, such as "Describe your typical day” or "Is anyone hurting you?"

TYPES OF ELDER ABUSE

PHYSICAL ABUSE — actions that cause bodily harm. EMOTIONAL ABUSE — threats or actions that result in mental stress, extreme fear, and emotional disturbance. NEGLIGENCE — failure to carry out responsibility for care or supervision or careless conduct that causes injury, isolation, or violation of the elderly person's rights. FINANCIAL EXPLOITATION — theft of money, property, or personal assets belonging to the older person by relatives or caregivers. Often, the eloerty person is deceived, coerced, threatened, or battered to force the relinquish-ment of assets to others.

INDICATORS OF ABUSE IN THE ELDERLY

Bruises, lacerations, or welts in various stages of healing Abrasions or rub burns caused by being tied or confined Pressure ulcers Twisting or crushing bone fractures or dislocations Head injuries and bald spots from missing hair Extreme dehydration Malnutrition Health problems without physical cause, such as headaches, back pain, chest pain, and nonspecific complaints Genital injury, especially with older women Severe anxiety, such as agitation and panic Self-protective reactions, such as distancing, cringing, and bracing against being struck, when caregiver is present Explanation for an injury that doesn't match the physical evidence Minimization of the extent and seriousness of an injury by the client or caregiver Marks from the use of restraints Physical effects from the overuse of medications, such as excessive sedation, staggering gait, blurred vision, and lack of coordination

NURSING DIAGNOSIS: RISK FOR VIOLENCE BY CAREGIVER

Probable Causes	Defining Characteristics
Family history of abuse Substance abuse Lack of resources to meet own needs Excessive dependence on family members	Rage reactions Use of physical force to handle situation Verbalization about inability to cope Verbalization of indifference or minimization of problems

Long-Term Goal The caregiver will verbalize effective ways to handle stressors and negative feelings.

Short-Term Goal #1: The caregiver will identify and discuss the circumstances and feelings that contribute to feelings of anger and loss of control.

Interventions and Rationales

• Have the client identify current stressors. The client needs to see the connection between stressors, frustration, and acting out behaviors.
• Work with the client to identify and express feelings. By working with the client to express feelings, the client can identify dai:y burdens and the difficulty of handling them.
• Talk about ambivalent feelings that commonly occur in stressful care giving situations. It's normal for the client to vacillate between love and hate feelings when under severe stress.
• Explore with the client strategies for making changes in the current life situation, such as giving appropriate attention to unmet personal needs and seeking outside assistance with the physical labor of care giving. Learning strategies for making changes empowers the client and reinforces personal confidence in decision-making skills.
• Explore with the client personal strengths that can be used to regain control of an overwhelming situation, such as spiritual affiliations or beliefs, problem-solving skills, and friends or relatives who can provide social support. When people feel overwhelmed by stressors, it's difficult for them to mobilize their strengths and problem-solving skills without assistance.

Short-Term Goal #2: The caregiver will identify strategies for effective coping and list ways to obtain assistance from significant others and community resources.

Interventions and Rationales

• Discuss nonviolent methods for handling anger and frustration such as appropriate verbal expression of anger and talking a situation out. Appropriate methods for releasing anger give relief to the caregiver and help prevent acting out and abuse of the elder.
• Work on identifying alternative behaviors for handling severe stress, such as exercise, crying, and laughing, which serve as effective ways to release tension and other strong, pent-up feelings. Assisting the client with mastering alternatives ways to manage stress helps decrease the incidence of violent behavior toward the elderly person.
• Have the client consider whether it's realistic to involve other family members in the responsibilities of caring for the elderly family member. Having a plan that incorporates other family members into the caregiving responsibilities on a regular basis car. decrease the burden of care for the primary caregiver. If others can’t or won’t participate, then the caregiver knows that the only respite option is community resources.
• Discuss with the client the importance of satisfying personal needs by taking vacations from the care giving responsibilities and reenergizing. Caregivers must focus on their own needs or else they risk overload and the possibility of regressing to abusive behaviors.
• Identify community resources and supportive others who can participate in some of the responsibilities of care giving. Examples are professional respite caregivers for in-home care and adult day-care centers for ambulatory elders. Community services and supportive others are essential for preventing caregiver burnout by providing assistance and breaks from responsibilities.
• Have the caregiver discuss the value of participating in family therapy or a support group that focuses on caring for the caregivers. Examples are Children of Aging Parents and the Alzheimer's disease and Related Disorders Association. Participating in therapy can facilitate the change from a violent to a nonviolent family and assist the caregiver with support and the guidance for coping with daily situations.

THERAPIES

Therapy is usually focused on family members and the issues that contribute to abuse as well as dysfunctional patterns identified by the family,

Family Therapy

• Assess the family for stress caused by exhaustion and feelings of being overwhelmed by care giving responsibilities.
• Identify personal problems or issues of caregivers, such as chronic illness, substance abuse, financial constraints, age-related changes, and crises such as widowhood, retirement, and loss of a job.
• Assess the difficulties that the family has dealing with the health care needs, chronic conditions, dependency, deterioration, and personality changes of a loved one.
• Teach family members how to communicate with one another in a clear and honest manner.
• Encourage the caregiver to explore anger, guilt, frustration, resentment, and hopelessness related to the aging person's situation.
• Work with the family to facilitate understanding of how hostile or angry feelings can foster neglect of the elderly person's needs. In this situation, the care giving relationship needs to be evaluated.
• Identify the pattern of violence, and work with the client to break the cycle of abuse that was learned and transmitted from generation to generation.
• Have the caregiver describe the relationship pattern that has evolved between the elderly person and the caregiver and salient events that influenced this relationship.
• Talk about abuse and violence that the caregiver may have experienced as a child because many people who abuse their parents were probably abused by their parents as children.
• Discuss the role reversal that may have occurred between the elderly parent and the adult child.
• Help the family understand that disagreement between the caregiver and the elderly person is natural and that people can agree to disagree.
• Help family members see that violence is never an acceptable way to cope with problems.

MEDICATIONS

• Elderly clients who are the victims of abuse are usually not treated with psychotropic medications.
• Elderly people may be suspicious of medications due to their senility, fears, or experience of being given medication to restrain them.
• For caregivers who are overwhelmed by their numerous responsibilities, antidepressants or antianxiety drugs may be helpful in addition to participation in therapy or a support group, (See Appendix D for medication information.)

FAMILY CARE

• In states where reporting is mandated, explain the need to report and to obtain assistance for the family.
• Discuss how the protective service agency can be a source of help with the needs and care of the elderly person.
• Focus on the need for and benefits of respite care.
• Identify and discuss the burdens associated with being a constant caregiver.
• Refer family members to counseling, therapy for addiction problems, anger management, or family of origin work.
• Focus on preventive interventions by teaching family members about normal aging and situations that can predispose one to abuse; assist family members with accessing community services for the elderly client.