Violence is the physical force exerted for the purpose of violating or damaging another person.

It is an unjust exercise of power, often resulting in physical injury. Abuse is the willful infliction of physical injury, mental anguish or both.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

A. BIOLOGICAL THEORIES
Implicated in both the facilitation and inhibition of aggressive impulses. Areas of the brain that may be involved : temporal lobe limbic system Amygdaloid nucleus

1. NEUROPHYSIOLOGICAL INFLUENCES

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

NEUROTRANSMITTERS implicated in the etiology of aggression and violence: a. Decrease in serotonin b. Increase in norepinephrine and dopamine Associated areas of the Brain Limbic structures :Emotional alteration Prefrontal and frontal cortices: Modulation of social judgment Amygdala: Anxiety, rage, fear Hypothalamus: fight or flight Hippocampus: Learning or memory

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

2. BIOCHEMICAL INFLUENCES Neurotransmitters norephinephrine, dopamine and serotonin plays a role in facilitation and inhibition of aggressive impulse. Consistent with the fight or flight arousal

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

3. GENETIC INFLUENCES Genetic Karyotype XYY. The evidence linking this chromosomal aberration has not yet been firmly established.

4.

DISORDERS OF THE BRAINOrganic Brain syndromes associated with various cerebral disorders have been implicated in the predisposition to aggressive and violent behaviors.
a. Brain tumors : limbic system and temporal lobes

b.Trauma to the brain: cerebral changes such as encephalitis and epilepsy

MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012

B. PSYCHOLOGICAL THEORIES
1. Psychodynamic Theory - Underdeveloped ego and weak superego 2. Learning Theory _ Modeling can result in maladaptive as well as adaptive behavior

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

B. SOCIOCULTURAL THEORIES
SOCIETAL INFLUENCES : Aggressive behavior is primarily a product of ones culture and social structures. Studies have shown that poverty and income are powerful predictors of homicide and violent crime. To this day, many people would agree that the statement All men are created equal is hypocritical in our society. Societal influences may also contribute to violence when individuals realize that their needs and desires are not being met relative to other people.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

BACKGROUND ASSESSMENT DATA

INTIMATE PARTNER ABUSE: Battering is a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner. The National Coalition Against Domestic Violence states:

Battering is a pattern of behavior used to establish power and control over another person through fear and intimidation, often including the threat or use of violence.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

1. The American Medical Association defines domestic Violence as:

An ongoing debilitating experience of physical,psychological, and /or sexual abuse in the home, associated with increased isolation from the outside world and limited personal freedom and accessibility to resources.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Physical abuse between domestic partners may be known as : a. Spouse abuse b. Domestic or family violence c. Wife or husband battering d. Intimate partner or relationship abuse 85% of victims of intimate violence were women women ages 16 to 24 experienced the highest per capita rates of intimate violence Most common reason for not reporting among women : fear of reprisal Among men, because it was a private or personal matter
MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012

Family violence is a primary public health issue in the United States. It is estimated that 50% of all Americans have experienced violence in their families.
Family violence occurs across many boundaries affecting all socioeconomic levels, genders, geographic areas, races, religions and occupations. Family violence also occurs across the lifespan. The victim may be a fetus, an infant, a child, an adolescent , an adult, or an elderly person.
MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

 grew up in abusive homes Battered woman views her relationship as male dominant Phenomenon learned helplessness may be applied to the womans progressing inability to act on her own behalf

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Battered women represent all age,racial,religious,cultural,educational and socioeconomic groups. Married or single, housewives or business executives Low self-esteem,adhere to feminine sex-role stereotypes and often accepts the blame for the batterers actions Feelings of guilt,anger,fear and shame are common Isolated from family and support systems

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Men who batter are characterized with low-self esteem Pathologically jealous dual personality Often in a great deal of stress, but have limited ability to cope with stress Typical abuser : very possessive and perceives his spouse as possession

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Phase I. The Tension- Building Phase the abuser blames the victim for problems in the abusers life. The woman senses that the mans tolerance for frustration is declining. He becomes angry with little provocation but after lashing out at her, may be quick to apologize Minor battering incidents may occur Woman accepts the abuse as legitimately directed toward her,she denies her anger and rationalizes his behavior.
MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

e.g.

I need to do better Hes under so much stress at work Its the alcohol. If only he didnt drink

May last from a few weeks to many months or even years.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Phase II. Acute Battering Incident ( serious abusive incident): The tension in the abuser is relieved by the abusive incident. The most violent and shortest lasting up to 24 hours May begin with the batterer wanting just to teach her a lesson Women feel their only option is to find a safe place to hide from the batterer The beating is severe

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Phase III. Calm, Loving,Respite ( Honeymoon)

The abuser becomes remorseful and promises an abusive incident will not happen again and begs for her forgiveness. The batterer becomes extremely loving,kind and contrite. He is afraid she will leave him and plays on her feelings of guilt and she desperately wants to believe in him. The loving phase becomes the focus of the womans perception of the relationship. Length of time can be so short

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

I got flowers today. It wasn't my birthday or any other special day. We had our first argument last night, And he said a lot of cruel things that really hurt me. I know he is sorry and didn't mean the things he said. Because he sent me flowers today. I got flowers today. It wasn't our anniversary or any other special day. Last night, he threw me into a wall and started to choke me. It seemed like a nightmare. I couldn't believe it was real. I woke up this morning sore and bruised all over. I know he must be sorry. Because he sent me flowers today.

I got flowers today, And it wasn't Mother's Day or any other special day. Last night, he beat me up again. And it was much worse than all the other times. If I leave him, what will I do? How will I take care of my kids? What about money? I'm afraid of him and scared to leave. But I know he must be sorry. Because he sent me flowers today. I got flowers today. Today was a very special day. It was the day of my funeral. Last night, he finally killed me. He beat me to death. If only I had gathered enough courage and strength to leave him, I would not have gotten flowers...today
MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012

REASONS FOR STAYING IN ABUSIVE RELATIONSHIPS:

1. 2. 3. 4. 5. 6.

Children Financial resources Fear of retaliation Lack of support network Religious reasons Hopefulness

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Erik Erikson (1963) stated: The worst sin is the mutilation of a childs spirit.

Children are vulnerable and powerless and the effects of maltreatment are deep and long lasting. Child maltreatment includes: a. Physical or emotional injury b. Physical or emotional neglect or sexual acts

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Physical Abuse: Includes any physical injury as a result of punching, beating, kicking, biting, burning, throwing,stabbing,chokinghitting,shooting,cuttin g ( with hand, stick, strap or other object ) Signs of Physical Abuse 1.Unexplained burns, bites, bruises, broken bones or black eyes 2.Has fading bruises or other marks noticeable after an absence from school 3.Seems frigthened of parents and protests or cries when it is time to go home 4.Shrinks at the approach of adults 5.Reports injury by a parent or another adult caregiver
MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012urns

Physical abuse may be suspected when adult/caregiver:

1. Offers conflicting, unconvincing or no explanation for the childs injury 2. Describes the child as evil, or in some other negative way 3. Use harsh physical discipline with the child 4. Has a history of abuse as a child

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Emotional Abuse: Involves a pattern of behavior on the part of the parent or caretaker that results in serious impairment of the childs social, emotional or intellectual functioning.
Examples of Emotional injury: a. Belittling or rejecting the child b. Ignoring the child c. Blaming the child d. Isolating the child from normal social experiences e. Using harsh and inconsistent discipline

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Behavioral indicators of emotional injury:

a. Shows extremes in behavior 1. Overly compliant 2. Demanding behavior 3. Extreme passivity 4. Aggression b. Either inappropriately adult ( parenting other children) or inappropriately infantile ( frequently rocking or head -banging) c. Delayed in physical or emotional developement d. Has attempted suicide e. Reports a lack of attachment to the parent
MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012

Emotional abuse may be suspected when the parent or older adult caregiver:
1. Constantly blames, belittles or berates the child 2. Unconcerned about the child and refuses to consider offers of help for the childs problems. 3. Overtly rejects the child

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Stealing money or assets of the victim. Denying the victim access to personal finances. Inappropriate use of the victims money or property.

Physical Neglect Includes refusal of or delay in seeking healthcare,abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. characterized by withholding or failing to provide personal care, personal needs, cleanliness, health care, social contact and the education and supervision of children. Emotional Neglect - Refers to a chronic failure by the parent or caretaker to provide the child with hope,love and support necessary for the development of a sound, healthy personality.
MS. JOCELYN-ALCERA NAZARIO, RN MAN 6/8/2012

Indicators of neglect: 1. Frequently absent from school 2. Begs or steal food for money 3. Lacks needed medical or dental care, immunizations or glasses 4. Consistently dirty and has severe body odor 5. Lacks sufficient clothing for the weather 6. Abuses alcohol or other drugs 7. States that there is no one at home to provide care.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Parent/caregiver: 1. 2. 3. 4. Appears indifferent to the child seems apathetic or depressed behaves irrationally or in bizarre manner abusing alcohol or other drugs

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

SEXUAL ABUSE : Is pressured or forced sexual activity including sexually stimulated talk or actions, inappropriate touching or intercourse, rape and incest .
INCEST Is the occurence of sexual contacts or interaction between , or sexual exploitation of, close relatives or between participants who are related to each other by a kinship bond that is regarded as prohibition to sexual relations. e.g. a. Caretakers b. stepparents c. stepsiblings

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

 Child sexual abuse profoundly affects development causing low self-esteem, self hatred, difficulty trusting and poor control of aggressive impulses. There is a high correlation between childhood sexual abuse and adult psychiatric disorders Victims of child sexual abuse often experience symptoms of post-traumatic stress disorders. Sexual assault is characterized by use of force in any sexual activity executed against the persons will.

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

1.
2.

3. 4. 5.

6.

7. 8.

Difficulty walking or sleeping Suddenly refuses to change for gym or participate in physical activities Reports nightmares or bedwetting Experiences a sudden change in appetite Demonstrates bizarre, sophisticated or unusual sexual knowledge or behavior Becomes pregnant or contracts a venereal disease particularly if under 14 Runs away Reports sexual abuse by a parent or another adult caregiver

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Sexual abuse may be considered when parent or adult caregiver: 1.Unduly protective of the child or severely limits the childs contact with other children, especially of the opposite sex 2.Secretive and isolated 3.Jealous or controlling with family members

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Saddock and saddock report that 90 % of parents who abuse their children were severely physically abused by their own mothers or fathers. A sexual perpetrator is typically male between the ages of 25 and 44 and married or cohabiting at the time of the offense
If the sexual perpetrator has a history of criminal behavior, it is generally crimes against property rather than people. The majority of perpetrators do not perpetrators do not have a history of mental illness

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

Onset of incestuous relationship typically occurs when the daughter is between 8 to 10 yrs. Old Begins with genital touching and fondling @ first, child accepts the advances as a sign of affection As it continues, child becomes bewildered,confused and frightened Relationship may become love-hate situation on the part of the daughter. Child strives for the ideal father-daughter relationship but is fearful and hateful Fathers may have an unconscious homosexual tendencies and have difficulty achieving a stable heterosexual orientation. The oldest daughter is most vulnerable

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

1.
2. 3.

4.

5.

Lack of trust unsatisfactory parent/child relationship Feel trapped Peer relationships are often delayed, altered, inhibited or perverted women: a. diminished libido b. vaginismus c. nymphomania d. promiscuity Men: a. impotence b. premature ejaculation c. exhibitionism

6. risk: a. PTSD b. sexual dysfunction c. somatization d/o d. compulsive sexual d/o e. depression f. anxiety

RAPE expression of power and dominance by means of sexual violence.

a. Date rape rapist is known to the victim - common location is the college campuses b. Marital rape- spouse may be held liable for sexual abuse directed at a marital partner against that persons will. c. Statutory rape- unlawful intercourse between a man older than 16 years of age and a woman under the age of consent ( 14 to 21).

1. 2. 3. 4.

Rapists childhood as mother-dominated Grew up in abusive homes Between ages 25 and 44 years old Many are either married or cohabiting at the time of the offense

The victim: 1. 15 months old and 82 years 2. high risk age group- 16 to 24 years 3. 75% are single women 4. Attack occurs in or close to the victims own neighborhood EMOTIONAL PATTERNS OF RESPONSE: 1.Expressed response pattern expresses feelings of anger,fear & anxiety through behaviors as crying,sobbing,smiling,restlessness & tension. 2. Controlled response pattern Feelings are masked or hidden, & a calm,composed or subdued affect is seen

1.
2. 3. 4.

5.

6.

Contusions and abrasions Headaches, fatigue, sleep pattern disturbances Stomach pains,n/v Vaginal discharge and itching, burning upon urination, rectal bleeding and pain Rage, humiliation, embarrassment, desire for revenge and selfblame Fear of physical violence and death

LONG-TERM EFFECTS: 1. Increased restlessness 2. Dreams and nightmares 3. Phobias.

1.
2. 3. 4.

Depression Suicide Substance abuse Psychotic behaviours

SILENT RAPE REACTION: 1. Anxiety is suppressed 2. Emotional burden maybe overwhelming

Rape- trauma syndrome related to sexual assault evidenced by verbalization of the attack; bruises and lacerations over areas of the body; severe anxiety.
Powerlessness related to cycle of battering evidenced by verbalizations of abuse ; bruises and lacerations over areas of the body; fear for her safety and that of her children ; verbalizations of no way to get out of the relationship Delayed growth and development related to abusive family situation evidenced by sudden onset of enuresis, thumb sucking, nightmares , inability to perform self care activities appropriate for age.

RAPE/SEXUAL ASSAULT
1.Communicate in the ff. manner : a. you are safe here b. I;m sorry that it happened c. Im glad that you survived 2. Perform the assessment in a quiet, private area 3. Stay with the victim 4. Assess stress level before peforming tx & procedures 5. Victim shld not shower,bathe,do uche or change clothing until an examination is performed

CHILD VICTIM
1.Ensure client safety, use appropriate introductions you are safe here, avoid touching the child without permission during the interview 2. Support the child during thorough physical assessment 3. Assess injuries
-

ELDER VICTIM
1.Assess for physical injuries 2. Report abuses to authorities 3. Remove from the abusive environment & contact elderly protective services 4. Discuss options for ensuring the clients safety a. temp. hosp. admission b. safe home c. court order of protection 5. Explore alternative living arrangements that are least restrictive & disruptive to the victim

ABUSED WOMAN
1. Communicate acceptance ,warmth & nonjudgemental attitude, avoid implying in any way that she is at fault for not leaving the abusive situation 2. Reinforce concern for her safety & her right to be free of abuse 3. Ensure all physical wounds, fractures & burns receive immediate attention. Take photographs with consent 4. Private area for concern 5. Discuss available options:

Use play activities like drawings

4. Explain all medical tests & procedures in terms a child can understand

MS. JOCELYN-ALCERA NAZARIO, RN MAN

6/8/2012

RAPE/SEXUAL ASSAULT
6. Obtain written consent for the exam, photographs,lab tests, release of information & lab samples 7. Assist with female pelvic exam & obtaining specimens to detect semen 8. Preserve any evidence 9. Treat physical injuries & provide safety 10. Document all events in the care of the victim 11. Refer to crisis intervention & support groups

CHILD VICTIM

ELDER VICTIM

ABUSED WOMAN
6. Respect victims decisions 7. Help the victim to develop a plan to ensure safety a. hiding an extra car & house keys b. call police if violence begins (neighbors) c. lists of phone numbers: -emergency shelter - legal aid - police -counselor -support grps

5. Report suspected abuse 6. Assess parents strenghts & weaknessess,normal coping mechanisms & presence or absence of support systems 7. Assist the family in identifying stressors,support systems & resources 8. Refer appropriate support groups

6. Provide lists of resources & support services a. adult protective services b.public legal services c. victim resource agency d. local unit on aging & 24-hr. elder abuse hotline e. guardianship arrangements 7. Obtain assistance for financial matters

SHORT-TERM:
1. 2. 3.

4. 5.

6. 7.

Has the individual been reassured of his/her safety? Is this evidenced by a decrease in panic anxiety? Have wounds been properly cared for and provision made for follow-up care? Have emotional needs been attended to? Have trust been established with at least one person to whom the client feels comfortable relating the abusive incident? Have available support systems been identified and notified? Have options for immediate circumstances been presented?

LONG- TERM EVALUATION: long after the immediate crisis has passed
1.

2. 3.

4.

5.

6.

7. 8.

Is the individual able to conduct activities of daily living satisfactorily? Have physical wounds healed properly? Is the client appropriately progressing through the behaviors of grieving? Is the client free of sleep disturbances ( nightmares,insomnia); psychosomatic symptoms (headaches, stomach pains, nausea/vomiting); regressive behaviors ( enuresis,thumb sucking,phobias); and psychosexual disturbances? Is the individual free from problems with interpersonal relationships? Has the individual considered the alternatives for change in his or her personal life? Has a decision been made relative to the choices available? Is he or she satisfied with the decision that has been made?

1.
2.

3.

CRISIS INTERVENTION THE SAFE HOUSE OR SHELTER a. individual and group counselling b. bureaucratic institutions e.g. police,legal representation, social services, child care, childrens programming, employment counselling and linkages c. resident : immediate crisis through grief process d. provides a haven of physical safety and security FAMILY THERAPY a. Focus: help families develop democratic ways of solving problems b. Active listening, assertiveness techniques and respecting the rights of others are taught & encouraged

c. Referrals to agencies that promote effective parenting skills e.g. parent effectiveness training Agencies that relieve stress of parenting e.g. Moms day out programs, sitter-sharing organizations, day care institutions

2. Psychological Abuse a. Yelling b. Insulting, name-calling c. harsh commands d. threats e. ignoring, silence, social isolation f. withholding of affection 3. Neglect ( intentional or unintentional) a. withholding food and water b. Unclean clothes and bedding c. Lack of needed medication d. Lack of eyeglasses, hearing aids , false teeth 4. Financial Abuse or Exploitation a. Misuse of elderly persons income by caregiver b. forcing to sign over financial affairs to another person against his/her will

Referred to in the media as granny-bashing and involves the abuse,neglect or victimization of an older person who is under the care of another person. Granny-dumping involves abandoning elderly individuals at emergency dept., nursing homes or other facilities, leaving them in the hands of others. RISK FACTORS: a. white, female age 70 and older b. Being mentally or physically impaired c. Being unable to meet daily self-care needs

EXAMPLES OF ELDER ABUSE 1. Physical abuse a. striking,hitting,beating b. bruising

c. cutting d. restraining

5. Sexual Abuse a. Sexual molestation; rape b. sexual intimacy against persons will FACTORS THAT CONTRIBUTE TO ABUSE 1. Longer life 2. Dependency 3. Stress 4. Learned violence

MGT: 1. Referrals 2. Reporting suspicions of elder abuse 3. Provide names/phone numbers for assistance 4. Follow-up visit by an adult protective service representative

SITUATION: Dina is an 18 year old freshman at the State University. She was extremely flattered when Jay, a senior football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Dina to the emergency department.
1.

Dina says to the nurse, Its all my fault. I shouldnt have allowed him to stop at the lake. The nurses best response is: a. Yes, you are right. You put yourself in a very vulnerable position when you allowed him to stop at the lake. b. You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack. c. Theres no sense looking back now.Just look forward, and make sure you dont put yourself in the same situation again. d. Youll just have to see that he is arrested so he wont do this to anyone else.

2. The priority nursing intervention with Dina would be: a. Help her to bathe and clean herself b. Provide physical and emotional support during evidence collection c. Provide her with a written list of community resources for rape victims d. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases 3. Dina is referred to a support group for rape victims. She has been attending regularly for 6 months. From this group, she has learned that the most likely reason jay raped her was: a. He had too much to drink at the party and was not in control of his actions b. He had not had sexual relations with a girl in many months c. He was predisposed to become a rapist by virtue of the poverty conditions under which he is reared d. He was expressing power and dominance by means of sexual aggression and violence